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Full text of "American Medicine"

AmeriGan Medicine 



A WEEKLY JOUENAL 
FOUNDED, OWNED, AND CONTROLED BY 
THE MEDICAL PROFESSION OF AMERICA 



GEORGE M. GOULD, Editor 



G. C. C. HOWARD, Managing Editor 



David Rieshan 
Allkk G. Ellis 
M. B. HArtzbll 
Norman B. Gwyn 
Helen Mckphy 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Rogh 
Bernard Kohn 
John W. (Jhcrohman 



COLLA.BORATOBS 

A. O. J. Kelly 
WiLMER Kbdsen 
John Knott 

LiAWRENCK HENDEE 

A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. Rhein 
J. Coles Brick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pyle 
D. Braden Kyle 

ECGENE LlNDAUER 

Alfred Gordon 



VOLUME XI 
JANUARY-MARCH, 1906 







PHILADELPHIA 
AMERICAN-MEDICINE PUBLISHING COMPANY 






Entered According to Act of Congress 
in the year 1906 

BY THE AMERICAN-MEDICINE PUBLISHING COMPANY 

In the office of the Librarian at Washington 



ALL RIGHTS RESERVED 






V) 



.11 



American Medicine 



David Riesman 
Aller G. Ellis 
M. B. Hartzkll 
Norman B. Qwyn 
Helen Mubphy 



GEORGE M. GOULD, Editor 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Rugh 
Bernard Kohn 
John W. Churchman 



G. C. C. HOWARD, Managing Editor 



COLLABORATORS 

A. O. J. Kelly 
Wilmer Krusen 
John Knott 
Lawrence Hendee 
A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. RHEIN 
J. Coles Brick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pvlk 
D. Braden Kyle 
Eugene Lindauer 
Alfred Gordon 



Published Weekly at 1321 Walnut Street Philadelphia by the American-Medicine Publishing Company 



Vol. XI, No. 1. 



JANUARY 6, 1906. 



15.00 Yeakly. 



The code of medical ethics almost invariably 
evolies lay comment of a flippant tone and there is a 
general tendency to looli upon it as something designed 
for tlie good of the doctors and not for that of the patient. 
To a nation honeycombed with trade unions it savors of 
nothing but unionism. It is not known tiiat the code 
has notoriously failed to accomplish any of tlie purposes 
of modern industrial combinations — and quite naturally 
failed too, because it was originally designed in ancient 
times and has survived to the present age for an en- 
tirely dilTerent purpose — the good of the patient. It is 
altruistic in the extreme and though it is a growth from 
ancient Greece, it is essentially Christian in spirit and 
practice. It originated long ages before unionism was 
even a dream. The egoistic purposes of union are more 
evident in the modern growth of medical organizations) 

I but even here the old altruism permeates the whole 
structure, for there is scarcely a subject taken up by 
paedical organizations which has not a direct bearing 
Bpon the public weal. Physicians are at last learning 
that they can best accomplish the purposes of their ex- 
istence by combinations with their fellows and not by 
feeble individual efforts — indeed, each one is made a 
stronger unit by the help of others even if he has an 
individual task, whether for attack or defense. 

The code is a system designed for physicians 
who are without org-aiiizatiou, each unit wholly 
independent of all others. They required rules of con- 
duct, for they had no organization to discipline them, 
for improprieties which would injure the sick. It 
is not at all unlikely that fear of losing caste in the 
future organization which is bound to come, will bring 
about a better attitude to the sick than even the 
code, but that code must of necessity be the basis 
of all coordination. In the meantime it is in order 
to resent the imputation of extreme selfishness of a 
code, every one of whose rules is especially designed to 
guard a helpless sufferer from a thoughtless word or 



action on the part of consultants. It is a time when a 
hint or unguarded action may cause intense suffering if 
not worse. It is bad enough to consider it a mere col- 
lection of rules for social amenities, but most ungracious 
to look upon it in the light of rules for walking dele- 
gates. It must be a low fellow, indeed, who cannot see 
the altruistic beauty of a code which is hoary, merely 
because it is good, yet a word of explanation now and 
then would, no doubt, prevent the sorry exhibitions of 
harmful criticism due to ignorance. 

Posing and Respectability as Medical Ideals. — 

For years those Britishers who are seriously concerned 
about anything have been most alarmed at the self-sat- 
isfaction, the asleep-and-dreaming indifference of the 
typical Englishman to the inefficiency and unideality of 
the nation. If the smiling cynics arouse themselves 
sufficiently to make an answer to the remonstrances of 
those who have not eaten of the lotus of success and 
complacency, that answer is a lisped laissez-faire. 
" Milton ! Thou shouldst be living at this hour ! " has 
no warning for them. How is it with medicine ? The 
yearly spectacle of pitiable addresses in medicine, in- 
troductory lectures, banquets, dinners, and receptions, 
of which the medical journals give monotonous and 
endless evidences, shows that the profession also "takes 
the tint and tone-color from him who dreams the 
dream." For half a lifetime to hunt down honorary 
degrees, to slip softly into the " gig of respectability," 
to be at last one of the elite, to pose, to repose, and 
then to pose again, to smile with uplifted eyebrows 
upon all serious endeavors that do not flatter the para- 
lytic Zeitgeist, to maunder and meander aimlessly, and 
with sapient superficiality, over old historic heroes, 
and "battles long ago," to ignore except with safe and 
glittering generalities, the living problems and realities 
of disease and suffering — all this is a deft way of travel- 
ing a broad smooth road marked with such strange signs 
as, " Made in Germany / " or " Imported from Amefi'ica I " 



2 Ahebican Medicine] 



EDITOEIAL COMMENT 



rjANUABY C, 1906 

LVOL. XI, No. 1 



Economic methods of eating are so important 
and so axiomatic tliat it really occasions some surprise 
that more is not known about the matter. Mr. Horace 
Fletcher, in his famous A. B. Z. books on nutrition, very 
wisely insists upon the necessity of slow mastication with 
abundant insalivation. It is really astonishing how 
badly people use the teeth nature gave them for this 
purpose. Children naturally bolt their food, so it is 
said, and adults retain the habit. Not having the 
digestive power of cats or dogs, which naturally bolt 
their food, it results that much of our food is undigested 
and wasted. At the very time that Mr. Robert Hunter 
in his great work on "Poverty" is calling attention to 
the fact that 10,000,000 Americans are underfed, Profes- 
sor Chittenden is apparently proving that little is needed. 
Surely, something in the way of teaching these 10,000,000 
how to utilize what they now waste is bound to lessen 
our annual sick list. The profession can well thank Mr. 
Fletcher for the great interest he is taking in these 
dietetic matters. It was due to his initiative and sub- 
stantial encouragement that the Yale experiments were 
carried out and medical science has been the gainer, 
even if it be subsequently proved that Chittenden has 
placed our needs too low. The stimulus given to the 
study of dietetics is the great gain, both for laity and 
profession. 

The great black plague is a new title which has 
been suggested for venereal disease, and is designed to 
call attention to the enormous number of cases which 
yearly arise, and the consequent destruction of health and 
life. It is said that of the 770,000 male Americans who 
reach early maturity every year, 60^ — nearly a half 
million — will become infected before they are 30. 
Many of these men marry before they are cured, 
and the infection of wives follows, causing 80 fc 
of deaths from female inflammatory troubles, 50^ 
of gynecologic operations, and 80 fo of infantile blind- 
ness. As 20 fc of all women are infected, may 
one accept the statement that, in the aggregate, 
virtuous wives have more venereal disease than 
professional prostitutes, although we know that, prac- 
tically, all prostitutes are infected? Nature is fully 
competent to put an end to this sad state of affairs in 
her own way and at her leisure. She simply destroys 
the most susceptible, so that in time either the disease 
will become mild through partial immunity, or there 
will be no men left who tend to consort with prostitutes. 
There is a suspicion that such racial immunity has 
already progressed quite a distance, for there is consid- 
erable evidence that in normal healthy men, gonorrhea 
is a self-limited disease, which terminates in spite of the 
treatment, or lack of it. In the weak and abnormal it 



persists, and defies treatment. Among the Japanese 
and Malays the process has apparently gone still further, 
for it is said that the disease is mild, as a rule, and 
receives but little attention. Yet this natural method, 
so appropriate for lower cultures, is not suitable for 
civilized environments in which the nonimmunes are 
survivinsf if they know how. The process is, therefore, 
much slower and, indeed, the susceptible will probably 
survive for all time, for they are the fittest if they have 
enough intelligence and can be taught to use it. The 
trend of civilization seems to be in the direction of re- 
stricting the social evil by elimination of its devotees. 

The Society of Sanitary and Moral Prophy- 
laxis, recently organized in New York, is the last of 
the innumerable efforts which have been made to restrict 
the evils of prostitution, and is one of the methods of 
the present crusade for the enlightenment of the young 
so that they may not do those things for which nature 
may have a death penalty. > The sexual Instruction of 
the students of high schools and universities is being 
taken up as a recognized part of the curriculum both 
here and in Europe, and is generally recognized as the 
best method for this limited class. A little pamphlet 
on venereal diseases and their prevention has been pre- 
pared by Prof. Pontoppidan, of the University of Copen- 
hagen. It contains the five lectures he delivers to his 
students and it has become quite popular, an English 
translation having also been published in London. Yet 
the great mass of boys leave school years before it is 
possible to give them instruction which they can under- 
stand, and it is to reach them that the new society has 
been organized. It is admittedly a link between the 
public and the medical profession, who by the very 
nature of their work cannot enter into such advertising 
without doing more harm than good. The founders 
desire to break the policy of indifference which has 
always prevailed among laymen, yet they depend upon 
the initiative of physicians and must be furnished with 
data and literature which young men can understand. 
Valentine, of New York, has already prepared a suit- 
able pamphlet on the boy's venereal peril. It is an 
elaboration of a paper read before the American Medical 
Association in 1903, and it has been extensively used. 
Until recently there has been no organized effort by the 
medical profession as a body. The New York Home- 
opathic Medical Society has initiated a movement in the 
proper direction, using as a basis an article by Holden, 
of Yonkers, on the physician's unpaid debt to youth —a 
title, by the way, which is most appropriate. If the 
medical profession cures and preserves the types which 
formerly perished, it is in duty bound to teach them 
how to avoid the dangers. 



jANtJABY 6, 19061 

Vol. XI, No. 1 J 



EDITORIAL COMMENT 



tAMKKICAN MEDICINI" 3 



Exaggeration in popular literature is the one 
great fault of all the previous attempts to restrict 
venereal diseases and prostitution. It is difficult to pre- 
pare anything in this line without using many adjectives 
and those in the superlative, and they impart a hys- 
teric tone which young men instantly detect and resent 
as of the old goody-goody, Sunday-school type, novy^ 
happily disappearing from religious literature. Since 
the regular medical profession is honor bound to take up 
its share of this modern sociologic burden, it is proper 
that some official recognition should be given to the 
various efforts to improve the conditions we ourselves 
are perpetuating in obedience to natural law. The 
preparation of temperate descriptions of the evils of 
illicit sexual congress are, therefore part of our public 
duties. Exaggerations in the literature of the temper- 
ance crusade did much harm to a worthy cause, and the 
mistake most not be repeated. Young men will be 
roused to contempt of our advice if we tell them dread- 
ful things of gonorrhea and syphilis, and they subse- 
quently learn that many of those infected entirely 
recover, and that the sins of the fathers are not neces- 
sarily visited on the children to the third generation. 
Above all else, it is well to remember that we are deal- 
ing with a powerful instinct, the satisfaction of which 
will lead men to risk their lives. It is to be expected 
that they will take lesser risks. Moreover, the men we 
; wish to reach are at the age of the most intense activity 
of the sexual system, and we cannot expect to do more 
than lessen an evil which is bound to exist for many 
generations. Nevertheless, this fact does not justify 
anything except commendation for this new crusade. 
The whole subject has been tabooed so long that it 
requires more moral courage than most of us possess, to 
tell all the truth. Yet there is reason to believe that an 
honest, open statement to young men of sense would do 
good. , 

The nervous diseases of school children are 

being studied more and more every year, and it is not 
too much to hope that eventually the causes will be dis- 
covered and removed, so that it will no longer be neces- 
sary as in the past to remove these poor unfortunates 
from school entirely. Meyer' is said to have found 
nervous diseases in 7 ^ of the school children he studied, 
while of those who had not attended school, only 2.0^ 
was afflicted. Though he is of the opinion that the 
school is merely one factor, and that the main cause is 
I to be found in an inherited nervous instability of some 
sort, yet the results are nevertheless a severe indictment 
of European school methods. If it is really a fact that 
modern civilized children are born with nervous tissue 



' Berliner klinische Wochenschrift, No. 17, 1905. 



of finer fiber, and therefore more irritable than that 
found in more primitive cultural states, it is a condi- 
tion to be given most serious consideration. We are no 
longer justified in arranging school work as though all 
the little ones were as phlegmatic as Indian babies. The 
natural environment of childhood is untrammeled 
freedom in the open air. The explosive shouts emitted 
as soon as a child is released from a session, prove that 
it has been under an exhausting restraint. Of course 
this fact has long been known by intelligent teachers 
who give their little charges numerous occasions to blow 
off steam, but it does seem that much more can be done 
than is done. If it is true that American children are 
of a more nervous type than those of northern Europe, 
we can expect to find a greater proportion of nervous 
diseases among them. It is said to be 10 fc in New 
York City if we include cases of bad mentality, and 
though the nervous affections alone are said to amount 
to but 1.2^, we are safe in assuming them to be much 
more numerous if we include the great class of " nerv- 
ous" little bodies which should be out rolling in 
the sand instead of sitting bolt upright on a hard, 
uncomfortable bench. The present mania of the Amer- 
ican mother to educate her babies long years before it is 
time, is merely one of the evil results of our system ; 
and since it is not possible to convince her of the harm 
done by such confinement, the problem before the school 
authorities seems to be to make the first few years of 
school approximate, as nearly as discipline will permit, 
the rollicking natural life of the babies in their charge. 
After all, it will remain for Americans to Show the 
European world that a big share of the " nervousness" 
and ill-health of school children is due to eyestrain, a 
truth as important as it is neglected. 

Overtasking of school children has been made 
the subject of a report by Consul-General Guenther, of 
Frankfort, Germany. He quotes Dr. Otto Dornblueth, 
a neurologist of that city, who writes against the prac- 
tice of afternoon sessions, and who states that an inves- 
tigation of 16,000 children showed that sickness among 
those who attended school in the forenoon alone is one- 
third less than among those attending both sessions. 
He does not state the health conditions of those who do 
not go to school at all, but from other sources we can 
assume them to have been still better. Dornblueth 
asserts as a fact that afternoon sessions exhaust the chil- 
dren, disturb digestion and tire their brains. No doubt 
everyone's personal experience in their own childhood 
days confirms his statements. In spite of his opinions 
as to the exhaustion due to afternoon school he makes 
the astonishing proposition to have a morning session of 
five hours, a relaxation of 15 minutes being provided in 



4 A.MKRICAN MEDIOINIBI 



EDITORIAL COMMENT 



rjANUARY 6, 1906 
LVOL. XI, No. 1 



every hour. This, of course, is entirely too long a time 
to deprive young children of food, and even in our 
high schools it is known to be productive of much harm 
now and then, unless the scholars are able to get a nour- 
ishing lunch at noon instead of the usual sweet bun and 
bit of candy. To supply some hot thick soup with 
bread and milk may smack of socialism, but might so 
strengthen the poor bodies as to lead to better scholar- 
ship. It is a plan which is being seriously considered in 
many parts of the world. For the youngest children a 
morning session of three hours seems more reasonable, 
and to overcome the objections of the mothers who want 
the State to look after their children in the afternoons 
because they cannot do it themselves, Dornblueth sug- 
gests the establishment of retreats where the little ones 
can be under proper nurses — a plan which is in actual 
practice in one of our western States. Though it sounds 
socialistic it is physiologic. It at least emphasizes the 
fact that in the lower grades our schools are custodial 
nurseries anyhow, where these mere babies learn good 
English by imitation. 

The dangers of excessive home work have been 
so long known, and the system has been so widely 
abandoned in the best American schools, that it is some- 
what of a surprise to find the matter under discussion in 
English journals. A parent complains in a London 
daily paper that his child is given on Friday evening 
enough work to occupy all of Saturday and some of Sun- 
day, too. The journal replied that hard work was neces- 
sary in a competitive world, and seemed utterly obliv- 
ious of the fact that such early strains were the best 
means of injuring a child so that it could not take up its 
future struggle for existence. The Hospital, of London, 
commented editorially upon this matter in a most 
wholesome way, but it seems rather primitive to Amer- 
ican pedagogs, who have settled such matters long ago 
. — theoretically, at least, if not practically. It says, 
" even the most thick-headed can recognize the folly of 
a system which enables a boy to come out first in a com- 
petitive examination at 14 years of age and qualifies him 
for a lunatic asylum at 40." The subject should be 
harped upon in this country, too, lest we forget. Prize 
scholars are not necessarily or even generally the suc- 
cesses in life — indeed, we have so many vigorous " self- 
made " men, whose vitality and energy is the result of 
normal development out of school, that the question 
naturally arises, why cannot we have more of such types 
from the schools? It seems almost heresy to say any- 
thing against the public school system — indeed, it is 
heresy to decry it as a system — but its defects, which are 
really being remedied as fast as they are discovered, are 
producing a distinct feeling of uneasiness in the minds 



of many thoughtful writers, and are dilated upon by its 
enemies. It is wisdom, then, to lessen the nerve strains 
of every description in this early period when strains are 
so disastrous, to the end that children in school will 
eventually be found to be as healthy and strong as those 
deprived of its vital advantages. 

Proposed London Sanatoriums for the Working 

Classes. — A meeting was recently held in London, No- 
vember 18, 1905, in support of a general scheme for the 
provision and maintenance of sanatoriums for tuberculous 
patients of the working classes. The meeting pretty surely 
inaugurated a new era of progress in the prevention and j 
treatment of "the great white plague." All classes of * 
society were represented : Royalty by Princess Christian, 
of Schleswig-Holstein ; either House of Parliament by 
some of its most prominent members, the Church of Eng- 
land by a member of the Episcopal bench, municipal gov- 
ernment by its authoritative officials, and the "aristocracy 
of labor" by hundreds of delegates from the friendly 
societies and great trade unions. Much — and very ex- 
cellent — advice was conveyed to the audience by the 
speakers. It was pointed out that the question of the 
prevention and cure of pulmonary tuberculosis was be- 
fore all things a working-class question ; that it afitected 
the working classes more vitally than any other in the 
whole community. Recent elaborate investigations 
made throughout a considerable proportion of the area of 
the French Republic have conclusively demonstrated 
that tuberculosis is the direct outcome of the economic 
conditions of the people ; that its prevalence is always in 
inverse ratio to the income of the affected classes ; and 
that the most potent factors in its production are the con- 
ditions which at present seem to be inseparable from 
modern industrial life. The manifestations of the dis- 
ease were always found in direct relation with bad air, 
bad food, small wages, long hours, and unemployment. 
In London alone, from 7,000 to 8,000 persons died an- 
nually of pulmonary tuberculosis, and it was esti- 
mated that about 80,000 were suflTering from some form 
of tuberculosis. To this enormous sura of sickness and 
death, the heaviest contribution by far was, of course, 
that furnished by the working classes. The annual loss 
in wage-earning due to the ravages of this disease was 
estimated at £4,000,000 in the English metropolis alone ! 
Of the Ancient Order of Foresters, the returns showed that 
pulmonary tuberculosis was responsible for 15 of every 
100 deaths which occurred. In fact, the tuberculous 
plague is the great tax which is paid by the workers for 
the maintenance of the present industrial system. En- 
couraging accounts were given of sanatorium treatment, 
and special emphasis was duly laid on the great impor- 
tance of prevention. It was proposed to build a sana- 



JANUARY 6, 1006T 

Vol. XI, No. 1 J 



REVIEWS 



{AHBKICAN MEDICIJStiB 5 



torium now — without palatial pretentions— which would 
then be under the control of the working classes them- 
selves. The want of sufficient accommodation up to the 
present was but too obvious ; hundreds were looking for 
admission and \V-aits of 20 weeks were of quite common 
occurrence. During that interval the disease often 
passed from the curable into the incurable stage. Such 
is the state of things which cries to Heaven for relief — 
also to terrestrial governments and financial and munic- 
ipal benevolence — in London as in other great (and, as a 
necessary consequence) overcrowded cities. We trust, in 
the interest of humanity, that the London movement 
may soon become cosmopolitan. 

Scholarsliii) Deinaiided and Illustrated. — " What 
have we to do with abroad?" asked a remarkable polit- 
ical economist, and perhaps some Americans may feel as 
he in regard to their educational institutions. If some 
of our exalted English critics would take up certain of 
our real philologic abuses instead of gibing at "Ameri- 
can linguistics," they could make us blush a deeper tint 
than we have heretofore been forced to show. How we 
stand with "abroad" is, nevertheless, of some impor- 
tance, although of less than how we stand with ourselves. 
A medical college in a large city of the United States 
sends out its "annual announcement," in which the 
kite-tails of literary and scientiflc degrees appended to 
the names of the faculty would seem heavy enough to 
prevent any rise of the kites in the higher atmosphere 
of indefinitenoss and ignorance. This assurance is in- 
creased by the warning to students solemnly laid down 
that "any mistakes in clearness and accuracy of expres- 
sion will be regarded as serious defects relative to spell- 
ing and grammar, or any lack of neatness in penman- 
ship." In the face of this stern condition, most slipshod 
in its own English, what must the students think, who, 
Hooking over the circular, find scarcely a grammatical 
sentence in it? What kind of a department is a " Lin- 
guistal Department," and what does a "Professor of 
Linguistal" teach? Micro, Medico, GenUo, Gyn, (for 
gynecology), etc., are printed as separate words, and the 
use of the punctuation box is the strangest ever seen in 
a printing office. As to spelling, the following words are 
illustrative : proptedentic, siceoloffi/ (because the students 
are mostly ladies ?), hermenentics, platis, abdominal pal- 
pitation (for palpation), pelvinetry, litholomy, balteriology, 
vemcreal, papier-machi models, eliolog, abdomun, ostrology, 
Van diseases, etc. The professors give "instructions," 
always, for instance, " on the functions important in 
practical medicine," and all animals used "are subse- 
quently autopsied." Among others, the following text- 
books are recommended : 



Physiology.— Foster Stewart. 
Therapeutics. — Woods. 
Diagnosis. — Dacosta. 

Surgery. — Uacosta, Walsham, Warren's Surgical. 
Eye.— Swangy, Eye, Ear, Nose and Throat. 
Genito, Urinary and Vernereal.— McReck Skin McReck Van 
Diseases. 

Nervous Diseases.— Danna. 

A serious purpose underlay the formation of the in- 
stitution, incorporated as "A Religious and Divine 
Healing Association " ; therefore one must as sincerely 
suggest only the best meant criticisms. All of us have 
an interest in the dignity and educational standards of 
our medical colleges. Nor do we see the least reason 
why theology and religion should not be conjoined with 
medicine in educational work, as in this, " The Medical 
and Surgical School of Christ's Institution." The circu- 
lar speaks feelingly of the far traveling accomplished 
" by the aid and assistance " " of our Lord and Saviour 
Jesus Christ"; of its combination of "preaching tlie 
Gospel to sin-sick souls, and healing those who were 
afflicted with many diseases in the Name of the Lord." 
The faculty speaks of itself as "consisting of men of 
infused energy and hence by the help of the Almighty 
and the patronage of general public, development is 
sure." 

BOOK REVIEWS 



A Compcnd of Histology. — By Henry E. Radasch, 
M.S., M.D. Philadelphia: P. Blakiston's Son & 
Co., 1905. 

This latest addition to the Quiz-Compends contains 
286 pages of text and 98 illustrations. The first 27 pages 
are devoted to technic and then follow in order descrip- 
tions of the various tissues and organs. The question- 
and-answer style is wisely omitted, the descriptions be- 
ing given in direct, sequential statements, which are 
unusuall.y clear ; for this reason the student should find 
little difficulty in comprehending the structure of even 
the most complex organs. The book is a helpful labora- 
tory guide and presents but few points for criticism. 
More careful attention to grammatic details would im- 
prove many sentences. We are unaware of authority 
for calling polymorphonuclear leukocytes eosinophils, or 
even finely granular eosinophils, either of which may 
be intended. 



Obstetric and Gynecologic Nursing. — By Edward 
P. Davth, a.m., M.I). Second edition, revised. 
Philadelphia, New York, London : W. B. Saun- 
ders* Co., 1904. 

Any book written by the facile pen of Dr. Davis is 
destined, by reason of its lucidity and scientific accuracy, 
to secure readers. The experience of the author as a 
teacher of obstetrics to large classes of medical students 
makes a textbook prepared by him for the use of nurses 
particularly valuable in this profession. The relation- 
ship between obstetric and gynecologic nursing is so 
close that the two subjects can be conveniently treated 
together. This work has been prepared especially for 
the use of the training-schools of two of the large hos- 



6 [American Mkdicinb 



EEVIEWS 



r.lANCABY G, 1906 
LVOL. XI, No. 1 



pitals of Philadelphia, and the nurse receives valuable 
advice as to the care of the mother during pregnancy, 
parturition and the puerperal state, and also as to the 
care of the child. Davis considers that the field of gyne- 
cologic nursing is narrow, as the majority of diseases 
among women are connected with pregnancy and partu- 
rition. The obstetric nurse fills a peculiar position and 
requires a special training which the ordinary surgical 
or medical nurse does not always receive ; and we can 
recommend this book most highly as a textbook for 
training-schools for nurses, as well as an instructive vol- 
ume for the practitioner of obstetrics. The style of the 
book is such that the mother herself may gain much 
useful information from it. 



Obstetrics for Nur.ses. —By Joseph B. DeLee, M.D. 
Fully illustrated. Philadelphia, New York, Lon- 
don : W. B. Saunders & Co., 1904. 

This volume is intended primarily for nurses, but 
medical students and practitioners will find in it much 
of value. It is the outgrowth of eight years of lectures 
to nurses in four different training-schools. Part one 
deals with the anatomy and physiology of the reproduc- 
tive system ; part second with nursing during labor and 
the puerperium ; and part third, the pathology of preg- 
nancy, labor, and the puerperium; while in the appendix, 
chapters are devoted to visiting nursing in obstetric 
practice, to the difference between hospital and home 
nursing, and to a complete dietary. The author dedi- 
cates the book "to the woman about to become a 
mother or with the newborn infant upon her bosom, 
wherever she has her tender burden," and certainly a 
strict observance of the lucid lessons here laid down will 
do much to diminish the morbidity and mortality 
among parturient women and newborn infants. Statis- 
tics show that of every 200 women who become preg- 
nant at least one dies, and that 7^ of the deaths of 
women between the ages of 20 and 40 years are due to 
puerperal infection. The trained nurse may do much to 
reduce this frightful mortality, and to decrease the 
number of women who seek relief from the injuries and 
diseases caused by pregi^ancy and parturition. 

Radium and Radioactive Substances. — By Chaules 
Baskerville, Ph.D. Philadelphia : Williams, 
Brown & Earle, 1905. 

The author of this excellent little book is head of the 
department of chemistry of the College of the City of 
New York. It is chiefly a review of the physical afid 
chemic properties of radium and its allied products, but 
the last chapter deals with therapeutics. We thus liave 
a concise and accurate exposition of what is known con- 
cerning radium and other radioactive substances, radio- 
active emanations, secondary radioactivity, the theory 
of radioactive phenomenon, and the physiologic action 
and therapeutic application of spontaneous radiation, 
and other forms of radiant energy. The illustrations 
are good and the recommendations conservative. 



The Diagnostics of Internal Medicine. — By Glent- 
WORTH Reeve Butler. Second revised edition. 
New York and London : D. Appleton & Co., 1905. 

The second edition of Butler's wellknown work on 
diagnosis appears in the same form as obtained in the 
previous edition with its several reprintings. It has 
been brought down to date without greatly increasing 
the size. The book has been very favorably received 
and this edition should increase its popularity. A new 
chapter on Diseases of the Mind, by Dr. W. A. White, 
and one on Medical Rontgen Ray Diagnosis by Dr. P. 
M. Pilcher, have been added. 



Progressive Medicine. — Edited by Hobakt Amorv 
Hare, assisted by H. B. M. Landis. "Volume 
VII, No. 3. 1905. Lea Brothers & Co., Phila- 
delphia and New York. 

This issue of Progressive Medicine is made up of 
four reviews. William Ewart discusses Diseases of the 
Thorax and Its Viscera, including the Heart, Lungs, 
and Bloodvessels; William S. Qottheil, Dermatology 
and Syphilis; William G. Spiller, Diseases of the 
Nervous System ; Richard C. Norris, Obstetrics. The 
names of these men are sufBcient guarantee of the thor- 
ough consideration of their respective subjects. The 
present number appears especially rich in personal com- 
ments by the reviewers, as they combine the various 
references. 



Handbooli of Physiology. — By Austin Flint. New 
• York : The Macmillan Company, 1905. 

Dr. Flint presents this latest addition to his numerous 
writings on physiologic subjects for the purpose of con- 
necting pure physiology with the physiology specially 
useful for physicians. It represents the instruction in 
physiology now given at Cornell, and treats the subject 
from a medical standpoint. Of the 850 pages of text^ 
the last 100 are devoted to embryology. We do not 
know of another book on this subject which presents the 
material in a way so easily grasped by the student ; the 
description of the cranial nerves particularly em{)hasizes 
this statement. Dr. Flint's long experience in teaching 
has shown him the needs of students and how to supply 
them. One statement should be corrected in subsequent 
editions, namely, that myelocytes form Sfo of the leu- 
kocytes in normal blood. A prominent feature of the 
book is the atlas of colored plates, containing 48 figures, 
reproduced in the actual colors of stained microscopic 
specimens. These figures are excellent, and represent a 
new departure in books of this kind. The author and 
the publishers deserve great credit for their persistent 
efforts in perfecting these plates. We regard the book 
entirely worthy of commendation. 

Vital Questions — By Henry Dwight Chapin, M.D. 
New York : T. Y. Crowell & Co., 1905. 

This little book of 189 pages contains chapters on In- 
equality, The Unfit, Poverty, The Child, Health, P^duca- 
tion, Success, Happiness, Religion, and Death. Parts of 
most of them have appeared in certain of the standard 
magazines, but even these have been greatly revised and 
changed. The author writes under the belief that the 
public may and can get from the medical profession 
much moi-e than the mere healing of their physical ills. 
Those who read the sound statements contained in his 
book will certainly agree with him. The work should 
be read by physicians and then recommended to laymen. 

Organotherapy or Treatment by Means of Prepa- 
rations «)f Varioiis Organs.— By H. Batty 
SiiAW, M.D. (London), F.R.C.P. Chicago: W. 
T. Keener & Co., 1905. 

This is an excellent and timely study of a very impor- 
tant subject. The physiology and pathology, the anatomy 
and chemistry of the various organs now used, the 
medicinal preparations, are carefully studied, and the 
therapeutic experiences and observations recorded with 
discrimination as well as comprehensiveness. We note 
a typographic error on page 152 in the citation of the 
recommendation to use epinephrin (suprarenal) in 
asthma, which was originally published in the Depart- 
ment of Treatment of American Medicine. The dose is 
from 1.6 mg. to G mg. (^i, gr. to ^V gr.) and not 0.09 gm. 
(U gr.) as stated in this book. 



JANUARY 6. 19061 

Vol. XI, No. 1 J 



REVIEWS 



[Ahekican Medicine 7 



Clinical Methods. — By Robert Hutchison, M.D., 
F.B.C.P., and Hakhy Raixv, M.A., F.ll.C.P. 
(Ed.), F.R.S.E. Chicago : W. T. Keener & Co., 
1905. 

The authors of this volume describe those methods 
of clinical investigation which aid us in arriving at a 
correct diagnosis. The first chapter deals witli the 
methods of case- taking in general, and includes a general 
scheme for the investigation of medical cases. The rest 
of the book is really an expansion of that scheme, each 
system being taken up separately, and the methods of 
investigating it described in detail. A special chapter 
is devoted to the clinical methods of examining chil- 
dren. A chapter is given on the examination of patho- 
logic fluids and in this, the ninth edition, the chapter on 
clinical bacteriology has been revised and in parts 
wholly rewritten. The book is thoroughly up to date, 
and will be useful to practitioners who wish to make 
themselves acquainted with the latest methods of 
clinical investigation. 

Diabetes Mellitus. — By Prof. Dr. Cari^ von Noor- 
DEN. Translated by J^i.orence Bitchanan and 
I. Walker Hall, M.D. New York: E. B. 
Treat & Co., 1905. 

This monograph of 211 pages is Part VII of Dr. von 
Noorden's treatises on the Disorders of Metabolism and 
Nutrition and contains the lectures recently delivered in 
the University and Bellevue Hospital Medical College, 
New York, under the Herter lectureship foundation. 
The 6 chapter-subjects are Definition, Pathogenesis of 
Glycosuria, The Acetone Bodies, Other Changes in 
Metabolism in Diabetes, General Course and Prognosis 
in Diabetes, and The Treatment of Diabetes. In an ap- 
pendix are furnished several food tables. This book can 
safely be styled the most enlightening and authoritative 
of the recent discussions on this difficult problem in 
nutrition. Dr. von Noorden gives at length the views 
of others, but, as in all his writings, he states positively 
his own convictions. The 50 pages devoted to treatment 
are well worth the price of the book. 

Hygiene and Public Health. — A Manual for 
Students of Medicine and Health Officers. By 
B. Arthur Whitelegoe, C.B., M.D., B.Sc. 
(London), F.R.C.P., D.P.H., and George New- 
man, M.D., D.P.H., F.R.S.E. Tenth edition, 
revised and enlarged. W. T. Keener & Co., 
Chicago, 1905. 

This small compact volume, so excellently written, 
deals with a large number of diversified subjects in a 
very clear and concise manner. The subjects treated are 
not only those ordinarily found in books on hygiene, 
but also include a discussion of the communicable dis- 
eases, instructions to health officers and the health laws 
of Great Britain. Although written for English health 
officers, the American health officer will find much in 
this Manual to admire in the clear-cut and concise Eng- 
lish methods in dealing with communicable diseases. 
The nine previous editions of this popular book have 
been exhau.sted in 15 years. There will be a demand in 
the United States for this work on account of our 
increased interest in public health work. 

The Principles and Practice of Medicine. — By Wil- 

r.iAM Osr.K.R. Sixth edition, thoroughly revised, 
from new plates. New York and London : D. 
Appleton & Co., 1905. 

The present edition of this standard work contains 
1,114 pages of text, but larger pages and new type allow 
of considerable increase of reading matter. The book is 
thoroughly abresistof the times and will fully sustain the 
popularity of the previous editions among all classes of 



physicians. As in other editions, treatment receives 
the least consideration. We believe every reader of 
Dr. Osier's book would be better pleased if he embodied 
in it more of his own rich experience, both in diagnosis 
and treatment, though we know any extended discussion 
is precluded by lack of space. The physician who refers 
to the volume is sure to find information on any medical 
subject. A number of small errors should have been 
caught in the proof, as, for instance, the misspelling of 
Kartulis and ateleiosis on pages 2 and 774 respectively. 
On page 3 the maximum diameter of Ammba dysenterice. 
is given as 20 microns instead of at least twice that size, 
as it should be. 

A Textbook of Physiology.— By William H. 
Howell. Philadelphia, New York, and Lon- 
don : W. B. Saunders & Co., 1905. 

Of the recent additions to the list of textbooks on 
physiology this must be regarded as one of the very 
best. Both in its style and in the subject matter pre- 
sented there is but little left to be desired. The author 
states that the necessary reduction in the vast amount of 
material at hand should, for the beginner, be made by 
the process of elimination rather than by condensation; 
the book is sufficient proof of the wisdom of this idea. It 
contains 886 pages with 271 illustrations, is well printed 
from clear type, discusses theories when they are an 
integral part of the knowledge of a subject, and in every 
way can be heartily recommended. 

Lectures Upon the Principles of Surgery. — Deliv- 
ered at the University of Michigan by Charle.s 
B. Nancrede, A.m., M.D., LL.D., with an 
appendix by William A. Spitzley, A.B., M.D. 
Second edition. W. B. Saunders & Co., Philadel- 
phia, New York, and London, 1905. 

In the second edition the work has been brought 
down to date, a more modern terminology employed, 
and the latest ideas regarding leukocytes, especially with 
reference to the various anesthetics with their effects, 
have been incorporated. The work deals mainly with 
surgical pathology and diseases and is presented in such 
a clear form as to make the work of great value to stu- 
dents. The appendix by Dr. Spitzley, which is devoted 
entirely to the various theories that have been advanced 
for inflammation from ancient times to the present day, 
is interesting as well as instructive reading. 

BOOKS RECEIVED. 

[Prompt acknowledgment of books received will be made In this 
column, and from time to time critical reviews will be made of those 
of Interest to our readers.! 

Physicians' Account Book. — By J. .1. Taylob, M.D. 
Medical Council, Philadelphia. 

Manual of Pathology.— By W. JI. Late Coplin. M.D., 
Professor ol Pathology and Bacteriology, Jefferson Medical 
College, Philadelphia, etc. Fourth edition, rewritten and en- 
larged, with i'Jb illustrations, many of which are original, 
and 10 colored plates. P. Blakiston's Son & Co., 1905. Price, 
$4.00 net. 

Immunity in Infective Diseases.- By T'^.lie Metchnik- 
OFF, Foreign Member of the Royal Society of London, Professor 
at the Pasteur Institute, Paris. Translated from the French 
by Francis G. Bennie, Pathologic Department, University of 
Cambridge. Macmillan Company, New York, 1905. Price, 
?5.2o. 

Surgical Aspects of Digestive Disorders.— By James G. 
MuMFORD, M.D., Visiting Surgeon to Massachusetts General 
Hospital, etc., in association with Arthur K. Stone, M.D., 
Physician to Out-patients, Massachusetts General Hospital etc. 
Macmillan Company, New York, 1905. Price, $2.50. 

Anatomy and Physiology for Nurses. — By LbRoy 
Lewis M.D., Surgeon to and Lecturer on Anatomy and Physi- 
ology for Nurses at the Lewis Hospital, Bay City, Michigan. 
Vltno. of 312 pages, with 100 illustrations. W. B. Saunders & 
Co., Philadelphia and London, 1905. Cloth, $1.75, net. 

A Manual of Diseases of Infants and Children. — By 
John Rwhbah, M. D., Clinical Professor of Diseases of Chil- 
dren, College of Physicians and Surgeons, Baltimore. 12mo. 
volume of 404 pages, fully illustrated. W. B. Saunders & Co., 
Philadelphia and London, 1905. Flexible leather, ?2.00, net. 



8 Amkrican MkdicinsJ 



amp:rican news and notes 



[J4NI7ARY 6, 1906 
Vou XI. No. 1 



AMERICAN NEWS AND NOTES 



GENERAL. 

Relieved from Philippine Duty. — The Surgeon- 
General of the army is going over the list of officers of 
the medical corps who, during 1906, will be ordered to 
this country from the Philippines and Alaska, having 
completed the tour of duty of the prescribed duration of 
two years and six months, with a view to naming their 
successors. 

American Derniatological Association. — At the 

twenty-ninth annual meeting held in New York city, 
December 28, 29, and 30, 1905, the following officers 
were elected for the ensuing year : President, IJr. M. B. 
Hartzell, of Philadelphia, Pa.; vice-president. Dr. 
Thomas C. Gilcrist, of Baltimore, M.D.; secretary and 
treasurer. Dr. Grover W. Wende, of Buffalo, N. Y. The 
next meeting of the Association will be held in Cleve- 
land, Ohio, in May, 1906. 

Personal. — A current rumor that Dr. Osier will 
give up the Regis professorship of medicine at Oxford to 
return to the Johns Hopkins is denied by his friends. — 
Dr. Howard S. Anders, of the Medico- Chirurgical Col- 
lege, gave an address recently before the Lebanon County 
Medical Society on " The Practical Relations of Certain 
Physical Signs to Prognosis and Treatment." — Dr. E. 
Li. Godfrey, of Camden, N. J., one of the best-known 
surgeons in New Jersey, is critically ill with appendi- 
citis in Pasadena, Cal., where he has gone for the benefit 
of his health, having been suflFering from overwork. He 
is secretary of the State Board of Medical Examiners and 
Assistant Surgeon-General of the State National Guard. 

Cholera at Manila. — There has been practically no 
cholera in the city of Manila during the past two weeks 
which could be correctly charged to the city itself. The 
cases reported have almost invariably occurred among 
persons who came from the provinces within 24 hours of 
the time they were taken ill with the disease. The 
situation in the provinces is not as encouraging as it 
might be. The number of towns infected is constantly 
growing and there is no longer a sufficient number of 
experienced medical men available to combat the dis- 
ease at the numerous places at which it has made its 
appearance. The rainy season is now about over and 
the disease will probably not spread so rapidly, provided 
the streams can be kept free from cholera. Heretofore, 
in the towns in which cholera appeared, the health 
authorities have had the assistance of the community in 
stamping it out. The disease has now made its appear- 
ance in Cavite Province, where a large portion of the 
population refuses to believe that the disease is cholera 
and they render no assistance whatever to the health 
authorities. In consequence, the disease is spreading 
there much more rapidly than at other places. 

EASTERN STATES. 

A Hospital for Animals. — Among the new enter- 
prises of Boston is the Commonwealth Hospital for 
Animals, which, within a few days, will take possession 
of its new building at 12 Cummington street, in the Back 
Bay district. As its name implies, the hospital is for 
the care and treatment of horses, dogs, cats, and house- 
hold pets. It will include special sanitary features, 
baths, operating-room, kitchen, outdoor exercising pad- 
docks, private wards, and a free clinic for animals of the 
poor on certain hours of the week. The hospital is con- 
trolled by a corporation, of which John I. Taylor is 
president and Samuel F. Wadsworth, M.D.V., agraduate 
of the Harvard Veterinary School, is managing director. 

NEW YORK AND VICINITY. 

An Epidemic Among Brooklyn Horses An 

unusual disease, which has caused the death of many 
horses in Brooklyn, is puzzling veterinary surgeons and 



the Society for the Prevention of Cruelty to Animals in 
that borough. The disease seems to be epidemic in 
Williamsburgh, where 250 animals have been attacked, 
fully 90% dying. 

Doctors and Druggists at Odds. — The physicians 
and druggists of Bayonne, N. J., are at odds over the 
question of counter prescribing, which the physicians 
say is too extensively indulged in by the druggists. The 
State law prohibits any but physicians from prescribing 
medicine. Counsel has been engaged by the druggists 
for a test in court. 

Brooklyn's New Health Board Building. — The 

Department of Health will soon begin the erection of a 
new Board of Health building in Brooklyn. The build- 
ing will be 184 ft. by 102 ft. by 115 ft. by 68 ft. in dimen- 
sion. This will give approximately 10,000 tq. ft., of 
which space a half will be occupied by the offices, 
which will be separate from the general building. 
There will also be a separate clinic and isolation ward. 
The Board of Aldermen has appropriated $295,000 for 
the purchase of the site. 

Low Death Record for 1005. — Vital statistics for 
1905 give New York City next to the lowest deathrate 
on record. The contagious disease deathrate is the low- 
est on record. In 1905 there were 103,852 births, against 
99,555 in 1904, an increase of 4,297. There were 42,667 
marriages, against 39,436 in 1904, an increase of 3,231. 
The deaths in 1905 were 73,450, against 78,060 in 1904, a 
decrease of 4,610. The deathrate per 1,000 of population 
in 1904 was 20.01, but this year it was reduced to 18.25. 
The real saving of life, considering births and deaths, 
was 7,042. 

PHILADEliPHIA, PENNSYLVANIA, ETC. 

Camden Vital Statistics. — The following vital 
statistics for the year just ended are reported for Camden, 
N. J. : Births, 1,652; deaths, 1,402; marriages, 2,338. 
This is an increase of 469 marriages over that of last 
year. There was also an increase of over 300 births, and 
a decrease in the number of deaths by 130. 

Orthopedic Hospital Trustees. — The annual meet- 
ing of contributors to the Philadelphia Orthopedic Hos- 
pital and Infirmary for Nervous Diseases took place last 
week, and the following managers were elected for three 
years : John VV. Brock, Samuel V. Merrick, and Law- 
rence T. Paul. 

Smallpox in Tamaqua. — Dr. Dixon, State Commis- 
sioner of Health, has received a message from Daniel 
Dechert, medical inspector for Schuylkill County, that 
twenty cases of smallpox had developed in Tamaqua in 
the last 48 hours. 

Doctors Form a Union — Physicians of Plymouth, 
Pa., are reported to have formed a union, fixed a sched- 
ule of fees, and agreed not to attend patients who are 
three months in arrears for professional services. 

State of New Jersey Board of aiedical Exam- 
iners.— Dr. "William H. Shipps has been elected acting 
secretary of the State Board of Medical Examiners of 
New Jersey, vice Dr. E. L. B. Godfrey, secretary, who 
has been granted leave of absence until May, 1906. All 
communications should be addressed during this period 
to Dr. William H. Shipps, Bordentown, N. J. 

Woman Physician for Girls' Home.— Dr. Mary 
DeHart, of Jersey City, has assumed her duties as med- 
ical director of the State Home for Girls, at Trenton, 
succeeding Dr. George Parker, of Trenton. 

New Beds for Almshouse. — Bids for 450 special 
beds for the patients at the Philadelphia Hospital have 
been received. They will be paid for out of an item of 
$3,000 in the special appropriation by Councils. 



January 6, 19061 
Vol. XI, No. 1 J 



FOEEIGN NEWS AND NOTES 



Taicbbican Medioikk 9 



Clinic on Scoliosis. — Dr. Robert W. Lovett, of 
Boston, assistant professor of orthopedic surgery at 
Harvard University, at tiis clinic at the Jefferson Med- 
ical College Hospital last week on "Curvature of the 
Spine," took the ground that many of these cases can be 
cured by proper gymnastics. He says that 33 fc of the 
children attending scjiool are afflicted with this malady, 
and braces tend to weaken the muscle trouble rather 
than cure the malady. The clothing should be sus- 
pended either from the neck or from the hips, instead of 
from the shoulders. The first step to remedy the condi- 
tion is to obtain mobility and improve the carriage of 
the patient ; the next step is to retain the mobility. 
This, he concludes, can be obtained through the use of 
gymnastic machines. The exercises should be carried 
out for from four to five hours daily and throughout two 
years. 

SOUrHEBN STATES. 

Yellow Fever Death in Galveston. — Patrick Fox, 
■who was pronounced to be suffering from yellow fever, 
and who arrived at Galveston, Texas, from Cuba with 
his brother, died Monday. 

Yellow Fever at Havana Mild.— Dr. Finlay, Chief 
of the Health Department of Havana, Cuba, says that 
Las Animas Hospital still contains three mild (rases of 
yellow fever, but that they are all expected to recover. 
There have been no new cases. 

The New Orleans Health Association. — The gov- 
erning committee will present a resolution to Governor 
Blanchard, stating that it is the sense of the Association 
that the nomination for State health officer he made 
from the recommendations of the State Medical Society. 
It has also been proposed to erect a permanent isolation 
hospital to cost $100,000. 

New Army Hospital at Washington, D. C 

Plans have been accepted by Secretary Taft. A limit of 
$300,000 for the cost of the building was fixed by Con- 
gress. Majors William C. Borden and W. D. MeCall, of 
the medical department, and Major Thomas Slavens, of 
the quartermaster's department, compose the board that 
was appointed to consider plans. 

Mortuary Report for New Orleans. — General dis- 
eases 30, diseases of the nervous system and organs of 
sense 18, diseases of the circulatory system 16, diseases 
of the respiratory system 19, diseases of the digestive 
system 14, diseases of the genitourinary system 14, puer- 
peral diseases 2, diseases of the skin and cellular tissue 1, 
malformations 4, of infancy 3, old age 5, external causes 9. 
Deaths — White (iS, colored 67 ; total white and colored, 
135. Deaths in hospitals and other institutions 39, 
deaths certified by the coroner 18, deathrate per 1,000 
per annum for the week ended Saturday, December 23, 
1905, whites 14.79, colored 39.14; total white and 
colored, 21.60. 

Scores Tuberculosis Theory. — Dr. D. F. Luckey, 
State Veterinarian for Missouri, expresses the opinion 
that tuberculosis is not hereditary with live stock. He 
bases his belief on the result of experiments covering a 
period of ten years. Dr. Luckey says he has recorded 
frequent cases in which both sires of a calf were in the 
last stages of tuberculosis, and yet an examination of the 
offspring by means of the tuberculin test showed it to be 
healthy and free from the germs of the disease. Owners 
of tuberculous cattle, he says, may breed them without 
fear of the offspring inheriting the disease. Dr. Luckey 
also has found that tuberculosis is highly contagious and 
that the introduction of one diseased animal into a herd 
may cause the entire number to contract the disease. 
His conclusions are directly opposed to the views of 
many veterinarians. 



WESTERN STATES. 

Doctors and Druggists. — Hostile petitions are 
being circulated in Iowa for signatures, and will later be 
presented as bills before the legislature. One has been 
drawn up by the physicians, and asks that pharmacists 
be restrained from counter prescribing, while the other 
is the work of pharmacists, and provides that physicians 
shall be prohibited from compounding prescriptions. 

Chicago's Low Deathrate. — From present indica- 
tions, the deathrate in Chicago for 1905 will be the lowest 
in the city's history. The lowest previous annual death- 
rate was 13.62 per 1,000 population, in 1904. The rate 
for 1905, if the low average continues this week, will be 
less than 13.5 per 1,000 population. There were 496 
deaths reported last'week, against 489 for the jjrevious 
week and 548 the corresponding week of last year. The 
principal causes of death were : Pneumonia, 83 ; pul- 
monary tuberculosis, 63 ; Bright's disease, 45 ; heart dis- 
eases, 38 ; violence other than suicide, 27. There were 
6 cases of suicide. In the loop district 36,293 pounds of 
flesh, fruit, and vegetables exposed for sale were con- 
demned as unfit for food. At the stockyards the city 
health inspectors condemned 195,438 pounds of flesh as 
unfit for food, 5,024 pounds of which had passed govern- 
ment inspection. 

CANADA. 

Smallpox Epidemic. — The health officer of Melanc- 
thon, Dullerin county, reports that up to Thursday last 
84 cases of smallpox had developed in the township. Of 
these 50 have fully recovered. He says the disease was 
allowed to spread as it was taken for chickenpox at first. 
Speaking to the provincial board of health. Dr. Sheard, 
of Toronto, repeated the opinion already expressed : "I 
am quite certain we are going to have an epidemic of 
smallpox throughout the province. I don't care who 
the medical health officer may be, he will have to meet 
the situation. We are going to have a large number of 
cases, and the situation will become serious. It is a 
question whether we should not have everybody vacci- 
nated." 



FOREIGN NEWS AND NOTES 



GENERAL. 

Environment and Criminality. — Professor Terriani 
says that 80^ of the child criminals of Italy are manu- 
factured by bad environment and inadequate education 
— in other words, by preventable causes; that 30^ of 
the criminals of the country are minors, and of these, 
So fc are thieves. 

Malta Fever.— The many Americans who visit the 
countries of the Mediterranean will be interested in the 
results of a scientific investigation of the socalled Malta 
fever, prevalent in the countries adjoining the Mediter- 
ranean sea. The Royal Society of England recently sent 
a commission of scientists to countries bordering the 
Mediterranean sea to investigate the causes of the 
socalled Malta fever. They have reported that the dis- 
ease is probably transmitted to human beings by domes- 
tic animals, especially goats. The examination of the 
blood of goats showed a plain reaction with reference to 
jNIalta fever, and a close examination of eight different 
flocks of goats had the result to demonstrate that about 
one-half of the number showed this suspicious condition. 
It was even found that some apparently healthy goats 
secreted the bacilli of the Malta fever in their milk in 
large quantities. It is, therefore, very probable that the 
consumption of goat milk transmits the disease to human 
beings. This conclusion is supported by the fact that at 
Gibraltar, where Malta fever is very common, the milk 
consumed is almost exclusively goat milk. 



10 Ajikbican Medicine) 



THE PUBLIC SERVICE 



rjANUARY 6, 1906 
LVOL. XI, No. 1 



OBITUARIES. 

Benjamin W. Taylor, aged 72, December 27, from 
pneumonia, at his home in Columbia, S. C. He was 
graduated from the medical college of the State of South 
Carolina, Charleston, S. C, in 1858. During the Civil 
war he served as colonel in the Confederate service, and 
was chief surgeon in Charleston Harbor at the fall of 
Fort Sumter. He was a member of the Southern Surgi- 
cal and Gynecological Association, Association of 
National Railway Surgeons, and the American Medical 
Association. 

Thomas Y. Aby.aged 65, December 24, from paraly- 
sis, at his home in (Quarantine, La. He was graduated 
from Tulane University of Louisiana medical depart- 
ment in 1866. He had served as surgeon at the quaran- 
tine station since 1884. At the outbreak of the Spanish 
war he offered his services, and was appointed acting 
surgeon to the Twentieth Infantry and was with the 
regiment at the battle of Santiago. 

James L. Harrima, December 21, at his home in 
Hudson, Mass. He was graduated from the Medical 
School of Maine, Bowdoin College, Brunswick, Me., in 
1857. He was a Grand Army man and prominent in 
Masonic circles. 

T. P. Coleman, December 26, as the result of in^ 
juries sustained in a railroad wreck, at his home in 
Oxford, Mis:'. He was graduated from the University 
of Pennsylvania, department of medicine, in 1859. 

George W. Doane, aged 81, December 20, at his 
home in Hyannis, Mass. He was graduated from Har- 
vard University Medical School, Boston, in 1844, and 
had been in active practice for over 60 years. 

Joliu Warner, aged 86, December 21, suddenly, at 
his home in Clinton, III. He served as a major in the 
Civil war, and since then has been devoting his time to 
banking business. 

Martin Lauber, aged 69, December 24, at his home 
in West Earl, Pa. During the Civil war he served as 
surgeon in the navy. 

John McClellan, aged 97, December 19, at his home 
in Woodstock, Conn. He was graduated from Yale 
University in 1833. 



THE PUBLIC SERVICE 



Changes in the Medical Corps of the U. S. Army 

for the week ended December 30, 1905 : 

Major Francis A. Winter, surgeon, will report at 
Zamboanga, Mindanao, for duty. — First Lieutenant 
William A. Duncan, assistant surgeon, will proceed 
to Cotabato, Mindanao, for duty, relieving First Lieu- 
tenant Edward B. Vedder, assistant surgeon, who will 
proceed to Camp Keithley, Mindanao, for duty. — First 
Lieutenant William R. Davis, assistant surgeon, will 
proceed to Camp Eldridge, Laguna, for duty. — Ulysses 
G. DoNSTON, sergeant first class, Whipple Barracks, will 
be sent to Manila, P. I., on the transport leaving San 
Francisco, Cal., about January 5.— Captain Elmer A. 
Dean, assistant surgeon, is granted leave for three 
months from about January 1. — Edward R. Murphy, 
sergeant first class, general hospital, Fort Bayard, will 
be sent to Manila, P. I., on the transport leaving San 
Francisco, Cal., about January 5. — Harry' M. Jen- 
nings, sergeant first class, general hospital. Fort 
Bayard, will be sent to Fort D. A. Russell for duty. — 
Major Frederick P. Rey'nolds, surgeon, is granted 
leave for one month from about February 1. — Second 
Lieutenant Charles S. Blakely', is granted leave for 
ten days from about December 23. — First Lieutenant 
Edgar W. Miller, assistant surgeon, leave granted for 
ten days is extended twenty days. — George F. Camp- 



bell, sergeant first class. Fort D. A. Russell, will be 
discharged under the provisions of G. O. 48, W. D., 
March 15, 1904. — First Lieutenant Hariiy S. Purnell, 
assistant surgeon, is granted leave for one month and ten 
days with permission to visit China and .Japan, effective 
about December 15.— So much of orders as directs First 
Lieutenant Harry S. Purnell, assistant surgeon, to 
proceed to the United States on the transport scheduled 
to sail about January 15, is amended so as to direct him 
to proceed on the transport scheduled to sail about 
January 5. — So much of orders as directs First Lieuten- 
ant Louis C. Duncan, assistant surgeon, to proceed to 
the United States on the transport scheduled about 
December 15, is amended so as to direct him to proceed 
on the transport scheduled about April 15. — First Lieu- 
tenant Samuel E. Lamhert, assistant surgeon, is 
granted leave for three months, upon being relieved 
from duty in this division December 15, with permission 
to return to the United States via Europe. — First Lieu- 
tenant Charles F. Morse, assistant surgeon, is granted 
leave for three months, upon being relieved from duty 
in this division December 15, with permission to return 
to the United States via Europe. — First Lieutenant 
William P. Banta, assistant surgeon, is relieved from 
duty in the department of the Visayas, and will proceed 
to Manila, reporting to the commanding general, depart- 
ment of Luzon, for duty. — First Lieutenant Cary A. 
Snoddy, assistant surgeon, is granted leave for one 
month, with permission to visit China and Japan, effec- 
tive about December 15. — Captain Clarence J. Manly", 
assistant surgeon, leave granted December 5 is extended 
one month. 

Changes in the Public Health and Marine-Hos- 
pital Service for the week ended December 27, 1905 : 

S. B. Grubbs, passed assistant surgeon, granted seven 
days' leave of absence from December 22, 1905, under 
paragraph 191 of the regulations. — M. H. Foster, pa.ssed 
assistant surgeon, relieved from duty at San Diego, Cal., 
and temi)orary duty at Galveston, Texas, and directed to 
proceed to San Juan, P. R., assuming the duties of chief 
quarantine officer. — Edward Francis, passed assistant 
surgeon, granted leave of absence for one month from 
January 17, 1906. — B. J. Lloyd, assistant surgeon, di- 
rected to proceed to Guayaquil, Ecuador, and relieve Act- 
ing Assistant Surgeon Luis F. Cornejo- Gomez. — J. H. 
Castle, chief of division of chemistry, hygienic labora- 
tory, granted three days' leave of absence. — A. L. Gus- 
TETTER, acting assistant surgeon, excused without pay 
for a period of twenty-five days from December 21, 1905. 
— Malcolm McKay, pharmacist, granted leave of ab- 
sence from December 13 to 31, inclusive.— Mathias 
Walerius, pharmacist, relieved from duty at Chicago^ 
111., and directed to proceed to Memphis, Tenn., report- 
ing to medical officer in command for duty and assign- 
ment to quarters.— F. J. Herty, pharmacist, granted 
seven days' leave of absence from December 18, 1905, 
under paragraph 210 of the regulations. 

Changes in the Medical Corps of the U. S. Navy 

for the week ended December 30, 1905 : 

R. K. McClanahan, assistant surgeon, having been 
examined by a Retiring Board and found incapacitated 
for active service on account of disability, not the result 
of any incident of the service, is retired from active serv- 
ice on furlough pay from December 19, 1905, under the 
provisions of section 1454, revised statutes. — B. H. 
Dorsey', assistant surgeon, ordered to Altoona, Pa., 
January 2, for duty with recruiting party No. 4. — H.W. 
JuDD, acting assistant surgeon, detached from duty with 
naval recruiting party No. 3, ordered home and granted 
leave until expiration of appointment as acting assistant 
surgeon. — E. E. Curtis, acting assistant surgeon, ap- 
pointed acting assistant surgeon from December 21, 1905. 



January 6, 1906"! 
Vol. XI, No. 1 J 



CORRESPONDENCE 



c ftMKRICAN MEDJCrNB 11 



CLINICAL NOTES AND CORRESPONDENCE 

(CommnnlcatlonB are Invited for this Department. The Editor Is 
not responsible for the views advanced by any contributor.) 



THE MARRIAGE OF THE TUBERCULOUS AND THE 
SIZE OF THE FAMILY IN THEIR BEARING ON 
THE TUBERCULOSIS PROBLEM. 



S. A. KNOPF, M.D., 

of New York. 

Associate Director of the Clinic for Pulmonary Diseases of the Health 

Department; Visiting Physician to Ihe Riverside Sanatorinra 

for ConKumptlvesof the City of New York; Consulting 

Physician to the Sanatoriuma at Gabriels, N. Y., 

fcicranton, Pa.. Bingham ton, N. i^., etc. 

Oa December 16 there appeared simultaneously in 
American Medicine and the Xew York Medical Journal 
two remarkable editorials, one entitled " The Marriage 
of the Tuberculous and the Resistance to Tuberculosis " 
and the other " The Size of the Family." Both of these 
editorials should give much food for thought to all 
interested in the tuberculosis problem. They are filled 
with unusually courageous utterances and are so out- 
spoken and full of common sense that it would seem that 
they should be read not only by all physicians but also by 
sociologists, reformers, and statesmen. 

As a starting-point for the discussion of the above- 
mentioned subjects, I may be permitted to reproduce 
here a sentence or two from those editorials. The one 
in American Medicine says : " The marriage of the tuber- 
culous is perhaps frowned upon by all physicians, the 
majority of whom would no doubt advocate the prohi- 
bition of such unions. It is considerable of a surprise, 
then, to learn that Dr. Charles Valentino, of Paris {Reoue 
Seientifique, July 5, 1905), has declared these marriages 
are desirable." From the editorial in the New York 
Medical Journal I beg leave to quote the following : 
" Surely, among the thoughtless and improvident, the 
reproductive impulse is sufficiently imperative without 
ill-considered utterances tending to weaken the sense of 
parental responsibility, which at best is none too strong. 
The social worker in the tenements and the hospital 
physician will probably agree that there are greater 
and more real evils in life than celibacy or the small 
family." 

That large families, particularly among the poor, do 
not tend to diminish but rather to increase the number of 
the tuberculous, I can prove by my own records, and this 
doubtlessly would be proved also by those of others if 
they have paid attention to the point at issue. It is 
invariably my custom when examining a patient to take 
down the family history, and one of the questions asked 
is "how many children were in your family?" and 
"were you born the first, second, third, etc.?" In the 
majority of cases, when there is a large family, it is the 
later or last born, the fifth, sixth, seventh, eighth, or 
ninth, who has contracted tuberculosis. This is to be 
explained, on the one hand, by physiologic reasons, the 
parents being in advanced life and less vigorous ; on the 
other hand, by economic reasons, the later born chil- 
dren cannot, because of increased expense, receive the 
particular care and the good and ample nourishment 
which it was the privilege of the first ones to receive 
when the family was still small. 

Have the often made statements that tuberculosis 
increa.ses the desire for sexual intercourse and that the 
procreative power of the tuberculous is really increased, 
any foundation ? I have known a number of patients 
who confessed to me that their sexual desire had become 
more intense than in their former healthy state. By a 
careful inquiry into the cause for this true or imaginary 
condition, I could almost invariably trace it to the fol- 
lowing : The patients had abandoned all occupations, 
not only physical, but also mental, and their thoughts 



dwelt upon sexual pleasures. Often in addition to this, 
the patient who formerly spent perhaps the greater part 
of his life occupied away from home, in workshop, office, 
or factory, has been compelled, owing to his infirmity, 
to remain constantly at home. 

I believe, without entering any further into this 
subject, we may say that here, and here alone, are to be 
found the explanations of increased sexual desires and 
the supposed increased procreative faculty. I have often 
been able to remedy this real or imaginary desire by 
directing the patient's attention to sound literature, and 
light, healthful outdoor occupation. The absolute pro- 
scription of sexual intercourse to the tuberculous hus- 
band or wife will probably never be carried out, nor 
will tuberculous individuals always obey when we 
forbid them to enter the matrimonial state. Some 
marry without knowing that they are tuberculous; 
some, even though they know it, marry, no matter 
what the doctor says, and there is no law to prevent 
them from doing so. 

Are we then justified to teach the tuberculous indi- 
vidual such preventive measures as to make the procrea- 
tion of a predisposed race impossible? I think so ; nay, 
I go even further in saying that I consider it the sacred 
duty of every physician to teach prevention, particu- 
larly when the wife is tuberculous. The life of a 
tuberculous woman is always endangered by pregnancy, 
and by prevention her own life will often be spared and 
she will have no occasion to transmit a tuberculous 
diathesis to an innocent child. I do not at all share the 
opinion of Valentino and some others who claim that 
tuberculous parents transmit to their children a natural 
immunity to tuberculous invasion. Twenty years of 
clinical work in tuberculosis has taught me rather the 
reverse, namely, that the physiologic poverty trans- 
mitted from tuberculous parents to a child rather invites 
a tuberculous invasion than confers an immunity, and I 
would not wish to consent to the procreation by tuber- 
culous parents on this theory of immunity. 

One need only to picture in one's mind the unsani- 
tary, dark and overcrowded homes in our tenement house 
districts, or even in some country regions where many 
of the untrained tuberculous live, to fully realize the 
multiple sources of infection to which a child is exposed. 
These postnatal infections, formerly ascribed to direct 
parental transmission, often take place through inhala- 
tion, ingestion, and inoculation at the same time, because 
of the child's close contact with the pulmonary invalid. 
The numerous cases of scrofulosis (which is only a milder 
form of tuberculosis), of Pott's disease and other typic 
forms of joint and bone tuberculosis in children of tuber- 
culous parents, would seem to me a strong evidence 
against the theory of transmitted immunity. A careful 
and unbiased study of the tuberculosis problem in its 
biologic, medical, and social aspects will probably 
bring every careful student to the same conclusion at 
which the distinguished editor of American Medicine 
arrived when, at the end of his editorial, he says : " We 
are not at all sure that Dr. Valentino will receive much 
support." 

The French school, under the leadership of Grancher, 
has recently resorted to a new method of saving the 
children of tuberculous parents. They discard the theory 
of immunity entirely, being strongly convinced of the 
transmission of a physiologic poverty and the great 
danger of postnatal infection and place the children in 
hygienic and health-producing environments. "L'Oeuvre 
de Preservation de I'Enfance Centre la Tuberculose " 
has for its main object to remove children of tuberculous 
parents from the centers of infection, either to good 
sanitary country homes, or to sanatoriums, until they 
are strong enough to resist the invasion of tuberculous 
diseases. The removal of the children is, of course, 
always done with the consent of the parents. The first 
complete report was given out at the recent Tuberculosis 
Congress in Paris and showed most gratifying results. 



12 



Amkrican Mki>ic:nk\ 



CORRESPONDENCE 



rjANUARY 6, 190« 
LVOL. XI, No. 1 



Thus, it would seem rational to teach prevention first, 
which should be done by the physician who attends 
tuberculous parents. To the latter, their duties toward 
themselves and their fellowmen should be plainly set 
forth and no one can do this better than the family 
physician. Second, it would seem wise when in the 
presence of children of the tuberculous poor to resort 
rather to the social prophylaxis as pointed out to us by 
our French colleagues than to rely on a probable 
immunity transmitted from parental source. 

The social aspectof thetuberculosis problem has of late 
roused more interest. Upon invitation I spoke last month 
on the social aspect of tuberculosis before the People's 
Forum in Yonkers, the Third Massachusetts State Confer- 
ence of Charities, and the Laennec Society for the Study 
of Tuberculosis at Johns Hopkins University. All three 
of these addresses I concluded by expressing the follow- 
ing thought, which may also serve as a concluding para- 
graph to the discussion of the marriage of the tubercu- 
lous and tiie size of the family. I feel very strongly on 
this subject, but I know that there are many worthy 
men and women, inside and outside of the medical pro- 
fession, who differ with me. However this may be, I 
am willing to fake the responsibility before the law and 
my God for each time I have taught a tuberculous hus- 
band and wife not to procreate a race predisposed to 
tuberculosis ; and with all due respect to the opinion of 
others, as a physician with, I may modestly claim, a 
somewhat large experience among the poor and poorest 
of the poor, the middle classes and also among the well- 
to-do, and as a student of sociology as well as of preven- 
tive medicine, I am not for quantity but for quality. 



RUPTURE OF THORACIC ANEURYSM INTO PLEU- 
RAL CAVITY, SIMULATING PLEURITIC EFFUSION. 

BY 

JOSEPH B. GREENE, M.D., 

of Fort Stanton, N. M. 

Passed Assistant Surgeon United States Public Health and Marine- 
Hospital Service. 

The following case seems of sufficient interest to 
report on account of its rarity and as showing the possi- 
bility of confusing blood in thorax with serous or puru- 
lent effusion : 

Patient, J. D., colored, aged 41, nativity, Kentucky ; 
admitted to the United States Marine Hospital Sana- 
torium at Fort Stanton, New Mexico, on January 2, 
1905 ; transferred from Louisville, Ky. The records 
show the family history is good ; that the patient had 
had syphilis several years ago, but that his general con- 
dition was good up to one year ago. Since that time he has 
several times required hospital treatment. He has had 
occasional hemorrhages from the lungs with slight rise 
of temperature. For several months after admission to 
this institution he continued to lose ground, and on 
July 10 began to complain of considerable pain in the 
left chest, with all the physical signs of effusion into the 
same side. His temperature varied from about 37° C. in 
the mornings to 38.5° C. in the afternoons. We at once 
used the aspirating needle at five different points at the 
base of the left lung, and were surprised at finding noth- 
ing. The patient continued to suffer severely both 
from pain and dyspnea, and on the evening of July 20 
suddenly died. 

The autopsy findings showed the entire left pleural 
cavity filled with dark clotted blood, which explained 
our failure to aspirate the pleural cavity. Incision into 
the' left lung showed at the apex a cavity the size of a 
small orange completely filled with an aneurysmal sac, 
which had extended from the arch of the aorta. The 
aneurysmal sac contained layers of fibrinated blood. 
The pleural cavity was connected with the aneurysmal 



sac through a small opening the size of a pencil point. 
The remainder of the left lung was infiltrated with 
tubercles. The heart and right lung were apparently 
normal. 



LIGAMENTUM PHRENICOCOLICUM DEXTRUM. 



BYRON ROBINSON, M.D., 
of Cbicago. 

To the Editor of American Medicine : — I note in your 
issue of October 7, an abstract of Dr. Longyear's article 
on '* A Study of the Etiology of Floating Kidney, with 
Suggestions Changing the Operative Technic of Nephro- 
pexy," in which he is quoted as saying that " Further 
investigation of the literature failed to enlighten the 
author as to the presence of any tendinous prolongation 
from the lower pole of the kidney." In an article on 
the cecum, published by me in the St. Louis Courier 
of 3Iedicine, for October and December, 1902, 1 have 
mentioned the band he is trying to describe. I termed 
it the ligamentum phreuieocolicum dextrum, and said : 
"The ligamentum phrenicocolicum dextrum inserted 
into the right colon at the junction of its lower and 
middle thirds often retains the cecum in its usual 
localitj', preventing its floating about or passing dis- 
tally into the lesser pelvis." In the same article I also 
said : " The cecum is maintained in position by three 
peritoneal folds, viz., a, the ligamentum phrenicocolicum 
dextrum, a fold derived from the ligamentum hep- 
atocavo duodenale and ligamentum hepatorenale. This 
peritoneal fold has a wide influence in preventing the 
cecum from passing into the pelvis, and also in prevent- 
ing the cecum from assuming the potential position — 
that is, wandering into the dangerous peritonitic region 
of the enteronic loops. In adult man the ligament 
appears to arise from the distal pole of the right 
kidney." This ligamentum phrenicocolicum is a colonic 
band, and the kidney is involved in it rather accident- 
ally. I noted this band in hundreds of autopsies, and I 
consider it the counterpart of the ligamentum phrenico- 
colicum sinistrum. 



AVOIDABLE NOISES. 

BY 

EDWARD A. ABBOTT, M.D., 
of Chattanooga, Tenn. 

To the Editor of American Medicine: — In the course 
of my efforts to obtain decent quiet for Chattanooga, the 
abatement of the evil of steam whistles seems of the 
utmost importance. Those who think as I do can be of 
great help to me in this crusade by getting their city 
authorities to enforce any laws they may have on the 
subject. For example, vvhy not make Philadelphia a 
model for other towns and cities? The physicians can 
do it ! The clergy have promised me their help and 
without doubt others can obtain assistance from the 
same source. Further, among the numerous depart- 
ments of the American Civic Association (headquarters 
in Philadelphia) is one dealing with "Nuisances." The 
head of this department is Frederick Law Olmstead, of 
Brookline, Mass. Why not ask the assistance of this 
association ? We could certainly furnish them with plen- 
tiful material for a pamphlet on " fool uproar." They 
have issued many illustrated paperson " City Beautiful " 
topics and are issuing " clipping sheets " for newspapers. 
1 believe they will gladly lend a helping hand and as a 
member of the association I will not neglect to remind 
them of the sick and the babies. 

If any reader of American Medicine can give me any 
information which will help the cause I would be ex- 
ceedingly grateful. 



Januaby 6, 19C61 
Vol. XI, No. 1 J 



PKOGNOSIS IN TUBEKCUL0SI8 



[Ahsbicah Mbdicinb 13 



ORIGINAL ARTICLES 



PROGNOSIS IN TUBEECULOSIS.^ 

BY 

LAWRENCE F. FLICK, M.D., 
of Philadelphia. 

Prognosis in tuberculosis depends : (a) On the viru- 
lence of tiie tubercle bacillus ; (6) on the dose ; (c) on the 
resistance of the host ; (d) on the coexistence of other 
microorganisms ; (e) on the amount of tissue which has 
been destroyed ; (/) on the duration of the disease ; {g) 
on complications arising from toxemias ; (h) on age ; (i) 
on race ; 0") on social condition ; {k) on environment ; {I) 
on financial resources ; {m) on temperament ; and (n) on 
character. 

Variability in the virulence of the tubercle bacillus 
has been demonstrated in animals and may be inferred 
from observations on man. The virulence of the bacillus 
can be modified at will in the laboratory by variation in 
the culture medium or by selection of the animal for 
inoculation. The benign bacillus may be made more 
virulent in this way and the virulent bacillus may be 
made more benign, but modifications in either direction 
can only be made gradually. A bacillus which has 
attained virulency, however, gives intense toxemia, 
varying in degree to practically all animals which are 
not immune. Even when there is some immunity, such 
a bacillus will give a more intense toxemia than will a 
milder bacillus. This, then, leaves no doubt that there 
is a variation in the virulence of the bacillus independ- 
ent of any variation which may exist in the soil. 

Clinically, we likewise have some evidence of varia- 
tion in virulence of the bacillus. Usually the first case 
in a family is more severe than those which follow. It 
is true this phenomenon may be interpreted in two 
ways, namely, in that the bacillus may become more 
benign as it goes from one member of a family to 
another, or that the soil may be modified gradually as 
members of the family resist implantation for a longer 
time. There probably is some truth in both views. A 
more striking phenomenon is the virulence of the 
bacillus in some families as compared with the benig- 
nancy of the bacillus in other families. Here again, 
however, the two interpretations are applicable. 

There is no way of demonstrating in which view 
there is most truth, but it may reasonably be inferred 
from our present knowledge that there is variation in the 
virulence of the bacillus. For practical purposes in 
formulating a prognosis, we may well be influenced by 
the character of the case from which a given case has 
been derived. 

The dose of the bacillus undoubtedly has a decided 
influence on the outcome of an attack of tuberculosis. In 
animals this has been proved. In man we have many 
ob.servations which enforce conviction that it is so. 
When the do.se is small the host is not only able to fight 
off the bacillus, but gradually gains in fighting qualities. 
When the dose is large, the toxemia seriously cripples 



> Read before the International Congress on Tuberculosis, 
in Paris, October, 1905. 



important organs of the body before the invaded organism 
can accommodate itself to the onslaught. This is the 
rule; there are exceptions. Under certain conditions 
which we do not yet understand the invaded organism 
staggers under the blow of a very large dose of tubercle 
bacilli, recovers itself, develops a strong immunity, and 
successfully throws off the disease. In this way in 
malignant cases of tuberculosis the subjects sometimes 
recover in a very short time. Ordinarily, when the 
dose is small, it is safe to give a favorable prognosis ; 
when large, one should reserve his opinion until he can 
see what is going to take place. 

Much undoubtedly depends upon the resistance of the 
host in the fight against tuberculosis. That there is 
great variation in the resistance of different individuals 
cannot be doubted. What constitutes this resistance is 
still a mooted question. It undoubtedly is a complex 
quality and perhaps may be due to different conditions 
in difiterent individuals. We call it immunity, but this 
word does not convey all that is meant. Both the 
laboratory and the bedside give evidence of an active 
and a passive resistance. In the active resistance, the 
blood or the tissues manifest a fighting quality 
against the tubercle bacillus; in the passive resist- 
ance the tissues apparently do not furnish the proper 
nutrition for the bacillus, leading to its degenera- 
tion and death. Then there is immunity against the 
toxin of the bacillus without immunity against the 
bacillus itself, and on the other hand there is immunity 
against the bacillus without immunity against the toxin. 
Clinically we see this in cases in which the tubercle 
bacillus develops in a host and leads to extensive 
destruction of tissue without giving rise to any symp- 
toms which attract attention on the one hand, and on 
the other cases in which the tubercle bacillus does not 
get a strong foothold and in which nevertheless there is 
intense toxemia. Again we may have immunity against 
the destructive powers of the bacillus and against its 
toxemia without immunity against its growth and 
development in the tissues. In such cases fibrosis takes 
place in the tissues instead of destruction and sometimes 
recovery follows and sometimes chronic invalidism. 
Immunity further may be distinguished as individual, 
family, and racial ; and as innate and acquired. It is 
questionable whether individual immunity ever exists 
except when acquired. Family and racial immunity 
usually have been acquired over a long period of time. 
Families in which tuberculosis has existed for genera- 
tions usually have considerable immunity and some- 
times an absolute immunity. Races which have been 
fighting tuberculosis for a long period of time have much 
more immunity than newer races which have not fought 
the disease so long. In formulating a prognosis it is 
well to bear in mind all the sources of immunity which 
an individual may have. In proportion to the immunity 
the prognosis is favorable. 

In man, in the white race at least, so long as tuber- 
culosis remains uncomplicated, the tendency to recovery 
is greater than the tendency to a fatal termination. 
Unfortunately, however, many pathogenic microorgan- 
isms fraternize with the tubercle bacillus for destructive 
purposes. 



14 



A.>(BS£CAN MBOZCINU 



PROGNOSIS IN TUBERCULOSIS 



CJasuary 8, 1906 
Vol. XI, No. 1 



The pneumococcus, the streptococcus, and the staphy- 
lococcus are well known confreres of the tubercle bacil- 
lus, and we have reason to believe that there are many 
others which we do not yet recognize. The pneumococcus 
in association with the tubercle bacillus gives rise to 
grave complications, which greatly depress the patient 
and seriously interfere with a successful fight against the 
disease. Studies recently made by Ravenel, Irwin, and 
myself seem to warrant the conclusion that the pneu- 
mococcus is perhaps the chief factor in hemoptysis. 
Streptococci and staphylcocci not only lead to intense 
toxemia, but probably are closely associated with the 
breaking down of tissue. Sometimes the pneumococcus, 
streptococcus, and the staphylococcus are all three asso- 
ciated at one and the same time with the tubercle bacil- 
lus, and when this occurs the downward tendency of the 
patient is usually rapid. Mixed infection of any kind 
makes the prognosis in tuberculosis graver, and should 
be carefully considered before an opinion is given in any 
given case. 

The amount of tissue which has already been 
destroyed in a given case of tuberculosis usually gives a 
very excellent basis to form a judgment as to the out- 
come of the case. When the destruction of tissue is so 
extensive as to make the physiologic action of the organ 
involved incompetent, an unfavorable prognosis as to 
the final issue should be given, even when the toxemia 
is mild. In such cases a favorable prognosis may be 
given as to the immediate future, provided the patient 
lives within the bounds of his physical capacity. A 
person with cavities in both lungs, and with the greater 
part of his lung tissue injured by fibrosis when he has 
good immunity against the toxemia of tuberculosis, 
may be restored to a condition of physical health and 
well-being, but not to a condition of physical activity. 
Such a person may remain relatively well for many 
years, provided he avoids all exertion and lives a careful 
life. When there is extensive involvement of tissue in 
one or both lungs, or in the lungs and in other organs of 
the body, all of recent development without destruction 
of tissue, the prognosis should be exceedingly guarded. 
These cases, by reason of their acuteness, sometimes 
eventuate in recovery, but more frequently prove fatal. 

The duration of the disease in connection with the 
amount of tissue involved or destroyed gives a fair indi- 
cation of what the outcome will be. When the disease 
has been of long standing, without much destruction of 
tissue or much fibrosis, the prognosis is favorable. In 
such cases the tendency to recovery is strong and has 
gone on for years without artificial aid. The condition 
may be recognized by healed lesions in perhaps both 
apices, a mild activity lower down in one lung, and par- 
tially obliterated pleura on one or both sides. When 
the disease is of long standing, with one or more dry 
cavities and fibroid tissues around them, even though 
there is an acute exacerbation going on, the prognpsis 
may be looked upon as favorable. The exacerbation 
here usually does not mean much and will run itself out 
in a short time. Many people have tuberculosis for a 
lifetime, with exacerbations at intervals of six months, 
a year, or even several years, always recovering from 
the attacks, and between exacerbations usually are in 



good health. Such cases rarely prove fatal. They are 
the chronic invalids, as a rule, who go through life fol- 
lowing a fairly active career, but never entirely well. 
When the disease is of short duration, and there is much 
tissue involved, the prognosis is unfavorable. 

Complications of various kinds gravely influence the 
prognosis in tuberculosis. The toxins of the tubercle 
bacillus and the toxins of the various microorganisms 
which fraternize with it often set up changes in impor- 
tant organs of the body which greatly cripple physio- 
logic action and lessen the resisting power of the 
individual. Nephritis is probably the most frequent 
complication of tuberculosis contributing to a fatal termi- 
nation. The penalty which the individual sometimes 
pays for his immunity is toxic nephritis. This has been 
demonstrated by experiments on animals. At the bed- 
side we often see patients, after having made a fair 
recovery, die of nephritis. Indeed, one of the most 
frequent immediate causes of death in tuberculosis is 
nephritis. The-urine should frequently be examined in 
all cases of tuberculosis of long standing, and when evi- 
dences of nephritis are found, the prognosis should be 
guarded. Pneumothorax is a serious complication in 
tuberculosis and always makes the prognosis grave. 
Empyema makes the prognosis unfavorable, but not 
necessarily grave. Pleuritic effusion and extensive adhe- 
sions of pleura aggravate the prognosis, but do not make 
it unfavorable. Dilated right heart sometimes contrib- 
utes to a fatal termination. Enlargement of the thyroid 
gland, either due to toxemia or to direct tuberculous 
infiltration, makes the prognosis less favorable. Any 
complication, indeed, which interferes with the physio- 
logic action of the body should be looked upon as an 
aggravating feature of the disease. 

The age of the patient should be taken into consider- 
ation in formulating a prognosis. Young people and 
old people usually show a greater tendency to recovery 
than do people in the middle time of life. The young 
show the strongest tendency to recovery of all. Chil- 
dren under 15 readily recover when placed under proper 
treatment and in proper environments. The age at 
which the disease perhaps shows greatest virulence is 
between 15 and 35. 

Race always should be considered when formulating 
a prognosis. Some races are much more prone to tuber- 
culosis and have it in more malignant form than others. 
As a rule the races which have been longest exposed to 
the disease show the greatest resistance. Jews have a 
wonderful immunity against tuberculosis and show a 
strong tendency to recovery when afflicted. They have 
almost complete immunity against the toxemia, less 
against the destructive power, and least against the 
growth of the bacillus. For this reason Jews have a 
high morbidity and a low mortality from tuberculosis. 
The Latin and the Teutonic races also seem to have a fair 
immunity. The Celts and above all the newer races in 
the struggle against the disease, such as the Negro and 
the American Indian, manifest a strong susceptibility 
and have the disease in rather a virulent form. A pos- 
sible explanation of the susceptibility of the Celt may 
be found in the historic fact that the Celt resisted the 
Roman invasion and the Romans in all probability 



January 6. 1906"! 
Vol. XI, No. 1 J 



PROGNOSIS IN TUBERCULOSIS 



IAmkkican Medio'nb 15 



spread tuberculosis throughout Northern Europe. The 
Negro and the American Indian were free from tubercu- 
losis until they came in contact with the white man and 
have only been subjected to the disease for a few 
hundred years. The American Indian has practically 
been exterminated by the disease and the Negro at the 
present time even in America has about twice the mor- 
tality of the white man. It is said that the African 
Negro is even more susceptible than the American 
Negro. 

The social condition of the patient has some influence 
on the outcome of the disease. Married life in both 
sexes makes the prognosis less favorable. The mother 
of the family in particular has many difficulties in 
struggling against the disease which other people have 
not. Widowhood in both the male and the female 
sometimes has an unfavorable influence upon the out- 
come on account of the melancholy and moroseness 
which such a condition engenders. Widowhood in the 
female, moreover, often is associated with hardships and 
this makes the prognosis unfavorable. 

The environment of the patient plays an important 
role in the prognosis of tuberculosis. When the condi- 
tions of life are good, pleasant, and conducive to happi- 
ness the chances of recovery are better than when these 
conditions are fraught with difficulties and are depress- 
ing. A bright, cheerful home, with plenty of sunlight, 
with good ventilation, good drainage, freedom from care 
and worry, affectionate, sympathetic relatives, friends, 
and associates, all contribute much to recovery. The 
healthful ness, cheerfulness, and good sanitary condition 
of the place of employment when the patient is em- 
ployed likewise are conducive to recovery. On the 
other hand, in a gloomy, dark, damp, dreary home, in 
which there is bad ventilation and bad drainage and a 
filthy condition, with sorrow, care, and sickness ever 
present, with fault-finding, irritable, disagreeable rela- 
tives, friends, and associates, the disease is apt to have a 
constantly downward course. When to the fatigues of 
labor are added bad ventilation and bad sanitary condi- 
tions, disagreeable associates in the place of employment 
the course of the disease is likewise rapidly downward. 
In many cases, indeed, the surroundings of the patient 
in his home and in his place of occupation practically 
determine the course of the disease and this should 
always be carefully considered in giving a prognosis. 

Much depends upon the financial resources of the 

patient. If he has ample means to purchase all that is 

necessary for his restoration to health and to provide for 

all his personal wants and the wants of those who are 

near and dear to him his chances of recovery are much 

better than when he lacks such means. Poverty is a 

powerful ally of the tubercle bacillus for destruction. 

For the very poor, recovery is difficult because they can- 

lOt keep up the mode of life which is necessary long 

mough. Even when people of this class are restored to 

hysical health in sanatoriums the restoration usually is 

nly temporary because the patients cannot keep up the 

roper life after leaving the sanatoriums. Many of the 

atients who recover in sanatoriums established for the 

poor relapse and die within a few years. Unless 

a patient can command the necessary resources for 



recovery in his home and can afford to live a careful, 
easy life for years after health has been restored the 
prognosis should be very guarded. Improvement in 
the home of the patient gives a better basis for a 
favorable prognosis than improvement under any other 
conditions because it takes place under the mode of life 
which is necessary to maintain good health after it has 
been restored. A guarded prognosis should always be 
given in cases in which improvement takes place under 
conditions differing materially from the conditions of 
home life. 

Temperament has some influence on the outcome of 
a case of tuberculosis. Patients who are sanguine and 
hopeful usually do better than patients of a lymphatic, 
despondent temperament. For one thing it is easier to 
get their cooperation and this means a great deal in the 
treatment of tuberculosis. A patient who always doubts, 
always looks upon the gloomy side of life, enters into 
every measure half-heartedly, rarely does well. He 
expects to do badly and he usually does as he expects. 
He balks at every little difficulty and usually balks at 
the time when his cooperation is of vital importance. A 
patient on the other hand who is determihed to get well, 
who is always pleased with every little step of progress 
that he makes, who aims high and strives hard to 
accomplish his purpose, nearly always does well. 
Nothing is too hard for him and he is ever ready to make 
an extra effort when an emergency arises. He comes 
through difficulties, if not completely victorious at least 
without much damage. When he has upsets he does 
not go back quite so far as he had come forward and 
between the intervals of his upsets he always makes a 
spurt forward, thus making constant progress. 

Character likewise plays some part in the struggle 
against tuberculosis. The patient of strong character has 
therein great protection against relapses and against ex- 
acerbations of the disease. You need but point out to him 
the dangers which he may encounter and he will avoid 
them. You say to him that he must live a very regular, 
even life, that he must deprive himself of many pleasures, 
that he must avoid all dissipations and he never flinches 
but lives up to all conditions that you lay down. He 
soon forms a habit of life which is not only conducive to 
recovery but to maintenance of health when once estab- 
lished. The result is that he gets well very easily and 
remains well when he has recovered. The patient of 
weak mercurial character, on the other hand, is con- 
stantly vacillating between what he ought to do and 
what he wants to do. Under the spur of fear he may do 
hard things for a while and live the life which is neces- 
sary for his recovery and well-being, but after he has 
made a fair recovery and begins to feel well he breaks 
loose from his anchorage and in a day or a week undoes 
all that he has done. He repents and again does well 
for a while but in due time again falls away. His prog- 
ress toward recovery is constantly interrupted and if he 
is ever fortunate enough to regain his health it is 
merely a question of time when he will have a relapse. 
Both the temperament and the character should be care- 
fully studied in every case before giving a prognosis. 

In forecasting the future of a tuberculous subject the 
physician should weigh carefully all matters bearing 



16 Ambkican Mbdicink] 



TUBERCULOSIS OF THE THORACIC DUCT 



rjANnARY 6, 190© 
LVOL. XI, No. 1 



upon the case, and even then should be guarded in his 
opinion. He should bear in mind that the tendency is 
always toward recovery, but that there are many im- 
pediments in the way of recovery. Restoration to 
physical health is comparatively easy, but the establish- 
ment of a condition of absolute sterility from the 
tubercle bacillus is difficult. Relapses take place even 
after years of apparent perfect health. The price of 
permanent recovery is constant and eternal vigilance 
and the pursuit of that kind of life which is necessary 
for recovery. A person who has had tuberculosis should 
not consider himself free from the necessity of leading a 
careful life, no difference how long he may have been 
well. Prognosis should, therefore, always be guarded 
and conditional. We may assure the patient that he 
will be restored to physical health and will remain well 
so long as he takes proper care of himself, but we should 
impress it upon him that his good health will only con- 
tinue so long as he does take good care of himself. 



TUBERCULOSIS OF THE THORACIC DUCT AND 
ACUTE MILIARY TUBERCULOSIS.* 

BY 

WARPIELD T. LONGCOPE, M.D., 

of Philadelphia. 

(Prom the Ayer Clinical Laboratory, Pennsylvania Hospital.) 

Tuberculosis of the thoracic duct has been recognized 
for over 100 years. In 1798 the condition was discovered 
accidentally by Astley Cooper,^ who described the 
lesions quite accurately and moreover interpreted his 
findings correctly, inasmuch as he considered that the 
great lymphatic vessel was the seat of scrofulous disease. 
Among the early writers AndraP is also credited by 
some with having described the same condition, but his 
notes are so vague that the correctness of the assumption 
is doubtful. It was, however, Ponflck ' who really first 
drew special attention to thoracic duct tuberculosis and 
emphasized its connection with acute miliary tubercu- 
losis, though he did not consider it as the cause of the 
generalized process. His original communications were 
made in 1877, and during the next year Weigert* 
reported his cases of vein tuberculosis and announced his 
conception of the origin and pathogenesis of acute miliary 
tuberculosis. In 13 such cases he found foci of tubercu- 
losis in the veins in 10 and of the thoracic duct in 2. 
From the nodules in the veins and in the thoracic duct 
he believed that the poison (this was prior to the dis- 
covery of the tubercle bacillus) was swept into the gen- 
eral circulation and thereby gave rise to the generalized 
acute process. According to Weigert, before a focus in 
a vein or lymph channel can be considered as the point 
of origin of the acute process at least four conditions 
must be fulfilled : 

1. The tubercle in the wall of the vein or duct must 
be older than the miliary nodules scattered through the 
organs of the body. 

2. The tubercle must be situated in a vein or large 
lymph vessel which is patent. 

®Read before the National Association for the Study and 
Prevention of Tuberculosis, at its first annual meeting, held at 
Washington, D. C, May IS and 19, IfWo. 



3. The poison must reach the surface of the nodule, 
i. e., communicate with the lumen of the vessel, a con- 
dition which is usually, if not always, satisfied in lesions 
of the thoracic duct. 

4, The tubercle must not be situated in the portal 
vein. 

Following Weigert's original work many investi- 
gators published observations which upheld and con- 
firmed his doctrines. Not only were the tuberculous 
nodules of veins described in connection with general 
acute tuberculosis, but thoracic duct tuberculosis, in 
which we are especially interested, was noted. 

Stilling,' in 1882, found tuberculosis of the thoracic 
duct in 5 of 18 cases of acute miliary tuberculosis, 
while Meissels,^ in 1884, published the descriptions of 8 
cases of acute miliary tuberculosis in some of which 
tuberculosis of the thoracic duct occurred. In the same 
year Koch,' in his splendid work on tuberculosis, re- 
ports 1 1 cases of acute miliary tuberculosis in 2 of which 
he mentions an involvement of the thoracic duct. Koch, 
of course, first demonstrated the presence of tubercle 
bacilli in the lesions of the veins and lymph channels 
and pointed to the actual dissemination of bacilli, the 
poison of Weigert, by way of the general circulation to 
the various organs of the body. Subsequently, Weigert,* 
in his own specimens, confirmed Koch's work regarding 
the presence of bacilli in the nodules in the veins and 
thoracic duct. 

Later, Brasch,' in a study of 24 cases of miliary 
tuberculosis, mentions an examination of the thoracic 
duct in 17 instances, and 9 times tuberculosis was dis- 
covered in this vessel. In 6 instances the tuberculosis 
was caseous in type. He emphasizes the relationship 
between involvement of the serous cavities and of the 
duct, and concludes that the infection is carried to the 
duct from the peritoneum and pleurae and not through 
the lymph-nodes. 

Hanau '" and Sigg," Helbing," and others, have also 
reported cases of thoracic duct infection, while more 
recently Benda" has called particular attention to the 
condition. In a very large proportion of cases of gen- 
eral miliary tuberculosis, 12 out of 19, he found tubercu- 
lous disease of the thoracic duct and believes the locali- 
zation of the process in this situation more than in any 
other gives rise to acute miliary tuberculosis. Benda 
considers that the primary infection of the vessel, 
whether it be vein, artery or thoracic duct, attacks the 
intima. The process arises by a deposition of tubercle 
bacilli upon the intima of the vessel. Naturally, this 
view has been frequently opposed. 

Weigert's work and that of his followers has been 
criticised and his views strenuously contested by Wild." 
Though not denying the occasional occurrence of macro- 
scopic lesions in the veins and thoracic duct. Wild ex- 
plains the origin of acute miliary tuberculosis diffierently 
from Weigert. He does not believe that the general 
process arises from an overwhelming invasion of the 
blood by tubercle bacilli liberated from a single focus of 
disease situated in a vein or the thoracic duct. In his 
conception the point of entry of the bacilli into the 
blood-stream is hidden and obscure. By undiscoverable 
routes the bacteria enter the circulation in small num- 



JANUARY 6, 19061 

Vol. XI, No. 1 J 



TUBERCULOSIS OF THE THORACIC DUCT 



[American Medicinb 17 



bers, and either here or in the organs multiply to pro- 
duce the general infection. Though Wild is upheld in 
his views by Ribbert,'^ whose pupil he is, his work has 
not been generally confirmed and his following is small. 
Weigert ^^ naturally confutes Wild's conclusions at every 
step. 

From a short review of the literature it will be seen 
that more and more importance is being attached to 
tuberculosis of the thoracic duct as a point of origin of 
the general acute form of tuberculosis, while the lesions 
of the veins, particularly the pulmonary veins, which at 
first received so much attention, are now becoming of 
secondary importance. Silbergleit," however, in a 
recent discussion of the subject, describes only 5 cases 
of duct infection among 23 well-studied cases of general 
acute miliary tuberculosis, though either vein or duct 
tuberculosis occurred in 95.6% of the total number. It 
may be said, however, that to exclude a lesion in the 
thoracic duct the vessel must be dissected from the 
receptaculum chyli to its entrance into the left sub- 
clavian vein, since in certain cases only a solitary tuber- 
culous nodule may be found in its extreme upper por- 
tion. 

In the following 30 cases of tuberculosis, in which 
the process was more or less generalized, especial atten- 
tion was paid to a study of the thoracic duct as a pos- 
sible point of origin for the generalized process. Of 
these ca.ses, 23 occurred at the Pennsylvania Hospital, 
and 7 at the Johns Hopkins Hospital. For this latter 
series I am greatly indebted to Dr. Wm. G. MacCallum, 
who placed the records of the autopsies at my disposal. 
The dissections of the ducts in most of the cases from 
the Johns Hopkins Hospital were made by Dr. Eugene 
Opie. 

Case I. — Male, aged 45, laborer, white, admitted to 
the Pennsylvania Hospital September 20, 1902, in 
delirium. Twenty-four years ago patient had pneu- 
monia, and for years has had a slight cough. For two 
weeks before admission he complained of weakness and 
pain in abdomen. For a few days he has been acutely 
ill with delirium, which his friends ascribed to excessive 
drinking. Examination showed no pronounced lesions 
in lung. Kernig's sign was present September 30. 
Death, October 1. Temperature below 101°, respiration 
36 to 40, pulse 120 to 136. 

Autopsy, October 1, No. 303. 

Anatomic Diagnosis : Chronic pulmonary tuberculo- 
sis, generalized acute miliary tuberculosis, tuberculous 
basil meningitis, with tubercles over ependyma, tuber- 
culous ulceration of ileum, tuberculosis of thoracic duct. 

Abstract of Autopsy Notes : The upper lobe of right 
lung is scarred and contracted by old fibrous bands. 
There are no cavities or large caseous areas. The lung 
is seeded with minute tubercles. The left lung also 
shows some scarring and contraction of upper lobe, but 
less marked than the right. Like the right lung, the 
cut surface is seeded with small tubercles, most numer- 
ous in the upper lobe. Spleen, liver and kidneys do not 
show macroscopic tubercles. The small intestines are 
the seat of a fairly extensive tuberculous ulceration, 
some of the ulcers being quite large. The retroper- 
itoneal and mesenteric lymph-glands are much enlarged, 
firm, and gray on section. 

Thoracic Duct. — The thoracic duct is thickened 
throughout its length, and the wall near the receptaculum 
chyli mea-sures about 2 mm. in thickness and .5 cm. in 
circumference. Enlarged lymph-nodes are attached to 
it throughout its length. On opening the duct, the 



surface is seen to be simply covered with fine raised 
granules, which can be distinctly felt. 

Microscopic Examination : Tuberculosis of lung. No 
tubercles found in spleen, liver, or kidney. Tuberculosis 
of meninges and tuberculous ulcers of intestines. 

Case II. — Male, colored, aged 29, laborer, admitted 
to Pennsylvania Hospital on August 17, 1902. Entered 
with wound in back about fifth dorsal vertebra ; opera- 
tion, laminectomy, followed by paralysis of lower 
extremities. Wound discharged pus and patient had 
high temperature. August 21, complains of cough; 
September 6, developed bed-sores ; September 14, cough 
again ; September 30, wound gradually healing, cough 
continues ; October 18, temperature very irregular, with 
frequent chills ; November 18, cough much worse, 
extreme emaciation. Death, November 18. 

Autopsy, November 19, No. 322. 

Anatomic Diagnosis : Chronic pulmonary tuberculo- 
sis, with cavity formation on left side. Generalized 
miliary tuberculosis ; tuberculous ulcers of intestines ; 
tuberculosis of mesenteric lymph-nodes ; tuberculosis of 
thoracic duct ; fracture of arch of seventh dorsal verte- 
bra ; transverse myelitis ; chronic pachymeningitis. 

Abstract of Autopsy Notes: The right lung is 
sprinkled with small tubercles. In the upper lobe of 
left lung there is a large cavity, 8 cm. in diameter, with 
irregular corded walls. Three smaller cavities are seen. 
The remainder of the lung is sprinkled with small 
tubercles and caseous areas. No macroscopic tubercles 
are found in spleen, liver, or kidneys. The small intes- 
tines show many small ulcers, most of them about the 
size of a grain of wheat. The mesenteric lymph-glands 
are enlarged, firm, and caseous. 

Thoracic Duct. — The receptaculum chyli is slightly 
enlarged. On opening the thoracic duct the walls are 
found to be thickened and the inner surface is distinctly 
roughened. Close inspection shows that the roughening 
is due to fine raised white glistening points thickly 
seeded along the duct. 

Microscopic examination shows tuberculosis of the 
lungs with great numbers of solitary tubercles in the 
spleen, liver, and thoracic duct, large areas of coagula- 
tion necrosis in the kidney and mesenteric lymph-glands, 
tuberculous ulceration of intestines. 

Case III. —Male, aged 22, laborer, white, admitted 
to Pennsylvania Hospital March 13, 1903. Patient is a 
spare young man ; gives history of 20 days' illness, with 
headache, pain in abdomen, considerable cough, expecto- 
ration, and fever. Lungs show harsh expiration and 
sibilant rales. Examination of other organs negative. 
March 14, leukocytes 2,400. During illness breath 
sounds are harsh and lungs show fine rales. Much 
cyanosis ; continuous even temperature between 102" 
and 104°. March 26, convulsion. Death, March 26. 

Autopsy, March 27. 

Anatomic Diagnosis : General acute miliary tubercu- 
losis, tuberculosis of mesenteric lymph-nodes, early 
tuberculous ulceration of ileum and colon, tuberculosis 
of thoracic duct. 

Abstract of Autopsy Notes: Both lungs are filled 
with small tubercles varying from .5 mm. to 2 mm. in 
diameter. They are most numerous at the apices. There 
are no chronic lesions. Spleen is densely seeded with 
fine glistening points, but none can be made out in liver. 
Many small yellow tubercles in kidneys. Intestines 
show many small, shallow ulcers 3 mm. to 5 mm. in 
diameter. The mesenteric lymph-nodes are very large, 
pale, and soft. One, the size of a walnut, is filled with 
necrotic material. The retroperitoneal lymph-glands 
are also very large and soft, but deep red in color. 

Thoracic Duct. — On opening the receptaculum chyli 
2 cc. or 3 cc. of a thin bloody fluid escape. The walls of 
the structure are simply sanded with small glistening 
gray and yellow dots, which stand up above the surface 
and occasionally measure from 1 mm. to 2 mm. in 
diameter. In the thoracic portion of the duct groups of 



18 American Medicine] 



TUBERCULOSIS OF THE THORACIC DUCT 



rjANUARY 6. 1906 
LVOL. XI, No. 1 



the same granules cover the walls and extend into the 
lumen. Throughout its length the ductadmits the knob 
of a pair of scissors 2.5 mm. in diameter. In places, 
however, it is difficult to pass the knob. Just at the 
point where the duct runs beneath the arch of the aorta, 
before the duct is opened a yellow mass about 2 mm. in 
diameter can be seen on the inner surface of its wall. On 
opening the duct at this point small, soft, caseous masses 
measuring about 2 mm. in diameter project into the 
lumen. The wall about is sprinkled with minute gray 
points. At the receptaculum chyli there is some slight 
thickening of the wall, but elsewhere it is thin and 
delicate. 

No foci of tuberculosis can be seen in stomach, 
esophagus, urinary bladder, prostate, seminal vesicles. 
Microscopic examination shows small single and con- 
glomerate tubercles in lungs, liver, spleen, kidney, 
adrenals, and myocardium, tuberculous ulcers of intes- 
tines, and a chronic tuberculosis, with caseation and 
necrosis of mesenteric lymph-nodes. 

Thoracio Duct. — Smear from the fluid in the duct 
shows myriads of tubercle bacilli. Sections made near 
the receptaculum chyli show a thickened wall covered 
with foci of necrotic material. Some of these are quite 
large and jut out into the lumen. Some are very minute 
and form only a slight projection, which is covered by 
endothelium. The wall of the duct, as well as the fat 
about it, is infiltrated with epithelioid cells and small 
round cells. In the wall of the receptaculum chyli 
there are many subendothelial areas of necrosis sur- 
rounded by epithelioid cells. A few contain giant cells. 
Sections stained in carbol fuchsin show great numbers of 
tubercle bacilli situated in the caseous areas. 

Case IV. — Male, aged 39, colored, admitted to 
Pennsylvania Hospital April 26, 1903. Patient is a thin 
negro. He was taken sick two weeks ago with cough. 
Over right lung fine crepitations and rales ; examination 
of other organs negative. April 28, leukocytes 2,900. 
Patient grew rapidly worse and died on May 4. Tem- 
perature throughout illness fairly regular, between 102° 
and 104°. Respirations rapid, 34 to 40 ; pulse 120 to 140. 

Autopsy, May 5, No. 406. 

Anatomic Diagnosis: General acute miliary tuber- 
culosis ; caseation of mesenteric lymph-glands ; tuber- 
culosis of the ependyma of lateral ventricles ; tubercu- 
losis of the thoracic duct. 

Abstract of Autopsy Notes : Lungs are seeded with 
minute tubercles and do not show any chronic lesion. 
Spleen, liver, and kidneys show many small tubercles ; 
no ulcers can be discovered in the intestines. The 
mesenteric lymph-nodes are large, some averaging from 
2 cm. to 3 cm. in diameter ; they are usually firm and on 
section show areas of coagulation necrosis. The retro- 
peritoneal lymph-nodes are also enlarged but not as 
large as the mesenteric. They are studded with small 
tubercles. The storhach, esophagus, pancreas, urinary 
bladder, prostate, seminal vesicles, and testes show no 
tuberculosis. 

The thoracic duct is large throughout its length and 
contains a moderate amount of milky fluid. On open- 
ing it the walls are seen to be studded at irregular inter- 
vals with small soft raised opaque yellow points the size 
of a pinhead, or with tiny dots. The walls are thick- 
ened. Just at the entrance of the receptaculum chyli 
into the duct there is a constriction, while beyond, the 
receptaculum is greatly distended with fluid. It meas- 
ures about 4 cm. in length and 2 cm. in width. On 
cutting through the constriction the wall of the duct is 
seen to be thickened at this point and practically occlud- 
ing the duct is a soft mass of caseous material. The re- 
ceptaculum, like the duct, is studded with minute 
tubercles. 

Microscopic examination reveals single and con- 
glomerate tubercles of lungs, liver, spleen, and kidney 
with caseation of the mesenteric lymph-glands. 

Thoracic Duct. — The walls are greatly thickened and 



in many sections are covered with masses of necrotic 
material. About this necrotic lining the wall is densely 
infiltrated with lymphoid cells and epithelioid cells occa- 
sionally assuming an arrangement suggestive of tuber- 
cle, but no typic tubercles are seen. The surrounding 
fat is infiltrated with the same cells and some new con- 
nective tissue. Tubercle bacilli are seen in enormous 
numbers in smears from the fluid in the duct and are 
found in moderate numbers in the sections where they 
are situated in the caseous areas. 

Case V. — Male, white, aged 19, laborer, admitted to 
Pennsylvania Hospital March 8, 1904. Patient is a 
well-nourished young man ; he has been sick 13 days 
with abdominal pain and headache. No change in 
organs except enlarged spleen. March 22, leukocytes 
7,700 ; April 4, some bloody expectoration, examination 
of chest negative. Leukocytes continually low ; gradu- 
ally worse, and death on June 7. Temperature quite 
irregular throughout disease, remittent and varying 
from below normal to 104°. Respirations about 28 ; 
pulse 100 to 120. 

Autopsy, June 10, No. 577. 

Anatomic Diagnosis: Generalized subacute tubercu- 
losis ; tuberculosis of pleurae and peritoneum ; gelatin- 
ous pneumonia; tuberculosis of bronchial and retro- 
peritoneal lymph-nodes ; tuberculous ulceration of in- 
testines ; tuberculosis of thoracic duct, cloudy swelling 
of liver and kidneys. 

Abstract of Autopsy Notes: The lungs show small 
and larger conglomerate tubercles together with areas of 
gelatinous consolidation. In the spleen, liver, and kid- 
ney are scattered caseous tubercle varying from 1 mm. 
to 1 cm. in diameter. In the ileum there are several 
small shallow ulcers. The bronchial and mesenteric 
lymph-nodes are very large and many are caseous or 
necrotic. 

Thoracic duct is distended with slightly milky fluid. 
When it is opened several small gray and yellow gran- 
ules are seen upon the inner surface of its delicate walls. 
They are not numerous and are only seen at irregular 
intervals. Smears from the fluid in duct show a good 
number of tubercle bacilli. 

Case VI. — Male, white, aged 16, laborer, admitted 
to Pennsylvania Hospital June 6, 1904. Patient is a 
young, poorly-nourished Italian boy. He has had a 
cough and has been spitting up blood for two months. 
Two days before admission he was exposed to cold and 
since then has had bad headache and felt worse than 
before. The physical examination reveals a positive 
Kernig's sign but no other definite signs. On June 8 a 
complete left-sided palsy developed. Patient gradually 
became unconscious and died on June 12. 

Autopsy, June 14, No. 578. 

Anatomic Diagnosis: Generalized tuberculosis; tu- 
berculosis of pleurse, pericardium, and peritoneum ; 
tuberculosis and caseation of bronchial and mediastinal 
lymph-nodes ; tuberculous ulceration of intestines ; 
tuberculosis of cerebral and spinal meninges and of 
ependyma ; tuberculosis of thoracic duct. 

Abstract of Autopsy Notes : The lungs are filled 
with small tubercles ; there are no chronic changes. 
The spleen and liver show tubercles, sometimes caseous, 
varying from 1 mm. to 3 mm. in diameter. The colon 
and ileum are the seats of moderate ulceration. 

Thoracic duct is delicate and contains but little fluid. 
On opening it several minute gray tubercles are 
scattered over its inner lining. 

Case VII. — Female, colored, aged 20, admitted to 
Pennsylvania Hospital February 15,1905. Patient is a 
young colored girl, admitted with delirium and com- 
plaint of stiff neck. Her mother and one brother have 
tuberculosis. The patient is supposed to have had in- 
fluenza. There is stiffness of' neck and inequality of 
pupils while Kernig's sign is present. No lesion found 
in other organs. The patient gradually developed 
exophthalmos and became stuporous and died in coma 



JanoakY 6, 1906T 
Vol. XI, No. 1 J 



TUBERCULOSIS OF THE THORACIC DUCT 



fAMERicAN Medicine 19 



on February 19. Temperature was below 102°. Pulse 
90 to 100 ; respirations 24, 

Autopsy, February 19, No. 665. 

Anatomic Diagnosis: Generalized acute miliary 
tuberculosis ; tuberculosis of bronchial lymph-glands 
with caseation ; tuberculosis of thoracic duct; tubercu- 
lous meningitis ; congestion of liver, spleen, kidneys, 
and lungs. 

Abstract of Autopsy Notes: Minute tubercles are 
found scattered very thickly through the lungs, spleen, 
liver, and kidneys. There are no chronic lesions dis- 
coverable in the lungs. There are no ulcers in the intes- 
tines. The bronchial lymph-nodes are the seat of an old 
tuberculosis with caseation. 

Thoracic duct is dissected out to its entrance into the 
left subclavian vein. Tlie portion which lies next to 
the vena azygos major is very much dilated, rather 
nodular in appearance, about the size of a lead pencil 
and bluish in color. Beneath the arch of the aorta the 
duct is narrowed, rather tough, and thick. The duct is 
opened from the cephalic end. At the narrow portion 
there is a definite stricture through which it is difficult 
to pass the point of a small pair of scissors. This stric- 
ture lies a few centimeters below the entrance of the duct 
into the vein. The walls are thickened and the duct is 
narrowed by caseous material and fibrous tissue, form- 
ing a mass the size of a pea. Above the stricture the 
duct is seeded with gray and yellow granules the size of 
a pinhead. The stricture measures 1 cm. in length and 
in its upper portion the lumen is only a few milli- 
meters in circumference. Below the stricture the wall 
of the duct is thickened and the lumen is dilated to a 
circumference of 1 cm. The wall is roughened and 
covered by minute gray and yellow points, which give 
it a granular appearance. This condition extends down 
the duct for about 10 cm. The granules gradually dis- 
appear, giving way to a thick white wall. The duct is 
filled with bloody fluid and red blood clots. In the 
region of the stricture the bronchial lymph-nodes are 
somewhat enlarged, firm, and deeply pigmented. On 
section they show small caseous areas and streaks of 
dense white fibrous tissue. The largest measures about 
2 cm. in diameter. There is no direct connection be- 
tween the process in the lymph-nodes and in the duct. 

Ca.se VIII. — Male, aged 29, negro, admitted to 
Pennsylvania Hospital April 1, 1905, complaining of 
pain in the left side. The patient had pneumonia ten 
years ago and a chancre three years ago. His present 
illness began three weeks before admission with cramps 
in the abdomen, pain in the left side, cough, and fever. 
These symptoms have persisted ever since. Physical 
examination shows a well-built negro. The important 
points are dulness, loss of vocal fremitus and breath 
sounds in the axilla and low in the back on the left side. 
Later the dulness became movable and the signs of a 
left-sided pleural eff'usion increased. The temperature 
showed daily rises and falls, occasionally reaching 102° 
in the afternoon. On April 19, 250 cc. of turbid bloody 
fluid were aspirated from the left pleura. After this the 
patient seemed somewhat better and left the hospital on 
May 3. He returned on June 24, complaining of short- 
ness of breath and swelling of the feet. The illness 
during the second admission was characterized by dis- 
tention and tenderness of abdomen, impaired resonance, 
diminished vocal fremitus and breath sounds in the left 
axilla and back, with slightly irregular continued mild 
fever and low leukocyte count. Later a friction rub 
developed over right chest. There was progressive 
emaciation. A cough developed, the patient gradually 
weakened, and died July 7, 1905. 

Autop.sy July 14, No. 742. 

Anatomic Diagnosis: General acute miliary tuber- 
culosis; tuberculo.sis of pleurse, pericardium, and peri- 
toneum; tuberculosis of thoracic duct; tuberculosis of 
bronchial, mediastinal, and mesenteric lymph-nodes; 
angioma of liver ; acute splenic tumor. 



Abstract of Autopsy Notes : Minute tubercles are 
scattered through the lungs, spleen, liver, and kidneys. 
There are no chronic tuberculous lesions in the lungs. 
There are no ulcerations of the intestines. Some of the 
mesenteric and retroperitoneal lymph-nodes measure 2 
cm. to 3 cm. in diameter. They are soft, gray, and on 
section the cut surface is seen to be studded with minute 
tubercles. The thoracic duct is dissected out from the 
receptaculum chyli to its entrance into subclavian vein. 
About the receptaculum and all along the duct there are 
enlarged lymph-nodes 2 cm. to 3 cm. in diameter. Almost 
all of them are seen on section to be studded with small 
gray and white tubercles. Duct is dilated throughout 
its length and contains slightly bloody fluid. Just above 
receptaculum there is a small caseous nodule protruding 
into the lumen. It is about the size of a pinhead. Seven 
centimeters above this there is a large caseous nodule 
.5 cm. in diameter. Throughout the duct one sees at 
intervals small gray and yellow granules lining the wall. 
They become more numerous above the transverse arch 
of the aorta. About 7 cm. below the entrance into the 
vein there is a yellow nodule about 2 mm. in diameter. 
Several nodules a little larger are found upon the valve 
just at the entrance of the duct into the vein, while for a 
short distance below this the intima is seeded with tiny 
gray points. 

Case IX. — Male, aged 26, admitted to Pennsylvania 
Hospital August 14, 1905. Patient is an Italian and 
does not speak English. For two weeks he has suffered 
from a swelling in neck just below ear. Examination 
shows enlargement of the lymph-nodes on both sides of 
neck. Tonsils are swollen. Heart is apparently normal. 
Left lung is dull below nipple line and there are few 
rales in upper part of lung on inspiration. Impairment 
of resonance at both bases with rales. The tumors in the 
neck were opened ; later the patient developed enlarged 
mesenteric lymph- nodes. On August 23 tuberculous 
glands were removed from the neck. 

Autopsy September 8, No. 762. 

Anatomic Diagnosis: Generalized acute miliary 
tuberculosis; chronic tuberculosis of prostate gland, 
mesenteric, retroperitoneal, peribronchial, mediastinal, 
and cervical lymph-nodes; tuberculosis of peritoneum, 
pleurse, and pericardium ; tuberculosis of thoracic duct ; 
acute splenic tumor ; cloudy swelling of liver and kid- 
neys ; tuberculous ulceration of intestines. 

Abstract of Autopsy Notes : Small tubercles, in the 
spleen ju.st visible, are scattered through the lungs, 
spleen, liver, and kidneys. There are no chronic tuber- 
culous lesions in the lungs. The collection of mesenteric 
lymph-nodes weighs 380 gm. and forms a mass which 
fills one's two hands. 

Thoracic dud is dissected from the receptaculum chyli 
to the arch of the aorta, but there it is lost in masses of 
caseous material. It is delicate and contains very little 
fluid. Near the receptaculum chyli a few minute gray 
and yellow points dot its walls. Smears from the fluid 
in the duct show fairly large numbers of tubercle bacilli. 

Case X. — Male, aged 47, admitted to Johns Hopkins 
Hospital and died on July 18, 1902. 

Autopsy July 19, No. 1964. 

Anatomic Diagnosis : Primary tuberculosis of the 
epididymis and seminal vesicles; tuberculo.sis of the 
thoracic duct ; acute miliary tuberculosis with miliary 
tubercles in lungs, liver, and kidneys ; small cavities in 
lungs. 

Abstract of Autopsy Notes : The mesentery contains 
large, caseous lymph-glands, the largest being about 1 
cm. in length. In the retroperitoneal tissue near the 
aorta there are a few enlarged lymph-glands which 
become more numerous and larger above the diaphragm. 

Thoracic duct is distended in its lower part and traced 
upward for about 12 cm., its wall becomes thickened and 
it has a nodular appearance, and there are opaque yellow 
masses which can be seen shining through the lumen. 
About midway between the diaphragm and the aorta it 



20 



A.MKKICAN MEDICINEJ 



TUBERCULOSIS OF THE THORACIC DUCT 



rJANUABY 6, 1806 

LVOL. XI, No. 1 



receives a large branch which has a similar appearance. 
Above the level of the arch of the aorta the wall be- 
comes soft and tubercles are not seen. 

Case XI. — Male, aged 50, admitted to the Johns 
Hopkins Hospital. 

Anatomic Diagnosis : Acute miliary tuberculosis ; 
tubercles in lungs, liver, and kidneys ; tuberculosis of 
thoracic duct, edema of lungs ; nodule in tonsil. 

Autopsy No. 1957. 

TlwroGic Duct. — On exposing the thoracic duct imme- 
diately above the diaphragm on the right side of the 
aorta it is found to be dilated to a diameter of about 3 
mm. Traced inward at a point 7 mm. below the highest 
point of the arch of the aorta the duct is found to be 
occupied by an opaque yellow mass, 4 mm. in diameter, 
occupying the lumen and shining through the wall. 
Above this point the wall of the duct is considerably 
thickened and the duct itself is dilated to about 6 mm. 
in diameter. Traced upward it is found to bifurcate a 
short distance before it enters the subclavian and jugular 
veins. The duct is opened from the receptaculum to 
its termination. Evidently the lower thoracic part is 
entirely free, but there are many lesions in the wall. 
The small nodule mentioned is found to occlude the 
lumen completely and consists of solid caseous material. 
About 2 mm. below this point there are a number of 
minute opaque slight elevations. Similar discrete and 
confluent elevations above the nodule involve a consid- 
erable portion of the wall. In the upper part of the 
duct there is adherent to the surface a small amount of 
fibrous material covered with blood. Immediately in 
contact with the duct, next to the caseous nodule occu- 
pying its lumen, is a large lymph-gland 2.5 cm. in length, 
succulent, and containing gray and opaque areas and in 
parts abundant coal pigment. The lymph-glands on 
the right side along the carotid artery are very greatly 
enlarged and have a similar characteristic appearance. 
Conspicuous is deep coal pigmentation. This gland 
forms a mass of considerable size. Beneath the arch of 
the aorta, at the bifurcation of the trachea, they form a 
large mass 3 cm. in diameter and black in color. 

Case XII. — Male, aged 43, admitted to Johns Hop- 
kins Hospital. 

Autopsy No. 1909. 

Anatomic Diagnosis : Tuberculosis ; primary in epi- 
didymis ; ascending genitourinary infection ; extension 
into lymphatics ; infection of thoracic duct; acute gen- 
eral miliary tuberculosis ; chronic left-sided pleurisy ; 
chronic diffuse pericarditis ; fatty degeneration of myo- 
cardium. 

The retroperitoneal lymph-glands are enlarged, dry, 
and somewhat opaque. The mesenteric glands are also 
enlarged and contain definite caseous foci scattered over 
the cut surface ; none is larger than a pinhead. 

Thoracic duct is found to be normal above the recep- 
taculum chyli ; within the latter situation it was almost 
occluded by a caseous mass the size of a bean. A few 
other caseous foci were also found. No other lesions 
were recognized. 

Case XIII.— Male, aged 53, admitted to Johns Hop- 
kins Hospital. 

Autopsy No. 1858. 

Anatomic Diagnosis : Acute miliary tuberculosis ; 
tuberculosis of the mesenteric and retroperitoneal lymph- 
glands ; tuberculosis of thoracic duct ; miliary tubercu- 
losis of lungs, liver, and kidneys ; cyst of left epididymis. 

The mesentery contains a large number of enlarged 
lymphatic glands, most numerous and largest at the 
base, where they frequently measure 2.5 cm. in length. 
On section of the smaller glands, they are found to be 
firm, gray, and succulent ; the larger glands are yellow- 
ish gray and in places quite opaque. In the retroperi- 
toneal tissue are found larger glands of similar charac- 
ter, in great part opaque, yellowish on section ; they are 
very numerous, particularly near the hilum of the left 
kidney and near the pancreas. 



Thorcuiic duct is found above the diaphragm behind 
the root of the aorta, to the right of the median line ; it 
passes upward behind the aorta toward the left. At a 
point midway between the diaphragm and the arch of 
the aorta it becomes enlarged and its outline becomes 
irregular, and at intervals can be seen groups of projects 
ing nodules of a grayish, somewhat opaque color, usually 
about 1 mm. across. These become most numerous 
below the arch of the aorta, and here the duct is dilated 
to a diameter of about 6 mm., and its wall is consider- 
ably thickened, being from .5 mm. to 1 mm. in thick- 
ness. The duct bridges the bifurcation of the jugular 
and subclavian veins, and is here in contact with a large 
group of much enlarged lymph-glands, the largest 
2.5 cm. across, similar in character to those of the 
abdomen. 

Hardened Section — Thoracic Duct: The intima is 
beset with small raised elevations consisting of tissue, 
which merges into the wall of the duct and involves the 
muscularis. This tissue consists of lymphoid and epi- 
thelioid cells. The superficial part of the nodule has, 
in most instances, undergone necrosis, stains homogene- 
ously with eosin and contains nuclear fragments. The 
section passes through a valve, and the wall of the 
pocket formed by it shows most extensive changes. 
Here almost the entire thickness of the duct is invaded 
by new-formed tissue containing giant-cells ; extensive 
caseation has occurred to the internal surface, which is 
covered by a layer of fibrin. In the adventitia of the 
duct are numerous lymphoid cells. Stained for tubercle 
bacilli, many were found ; they are particularly numer- 
ous in the caseous material near the internal surface of 
the duct. 

Case XIV.— Male, aged 24, admitted to Johns Hop- 
kins Hospital. 

Autopsy No. 256. 

Admitted to hospital September 18, 1891 ; died 
December 1, 1891 ; farm laborer. Complained of pain 
in side, shortness of breath, fever. Parents both died, 
probably of tuberculosis. Patient always healthy when 
young ; frequently caught cold ; malaria two months 
ago, sharp attacks, lasting two weeks. Five days ago 
had bad pain in side, lasting 20 minutes ; breathing, 
painful ; no chills ; no cough before. Had been exposed 
to wet. Bowels regular ; pain better ; coughing pain- 
ful ; no alcoholic or venereal history ; no genitourinary 
trouble ; urine, hyaline casts, faint diazo, no albumin ; 
specific gravity, 1,020. 

Present Examination : Well nourished, mucous mem- 
brane good color; tongue whitish coat; slight general 
erythema all over trunk ; faced flushed ; nervous look ; 
temperature, 102.6°; pulse, 104; tension, dicrotic. Reso- 
nance and respiration good in front and left back ; 
below angle of right scapula and below fifth rib in right 
axilla, dulness. Vocal fremitus diminished, but present. 
Voice sounds somewhat nasal. Fine crepitus, not 
increased by cough. Heart — nothing remarkable. Abdo- 
men—splenic dulness almost obliterated by tympany ; 
not palpable. Liver — sixth (lower border) to costal 
margin, no tenderness ; no gurgling ; no rose spots. 
September 21 : Urine, hyaline casts, no albumin, 
intense diazo. September 22: Hypodermic needle in- 
serted over dull area ; no fluid obtained ; general range 
of temperature lower ; patient seems bright ; no splenic 
enlargement ; dulness in right back more marked ; 
feeble respiration ; no abdominal symptoms ; tempera- 
ture, 103°, 100°, 102°. September 29 : Two small papules 
(in addition to others noticed before) on back. Septem- 
ber 30 to October 1 : Temperature normal, rising again ; 
diazo reaction reappears in urine after several days' ab- 
sence ; urine negative, lungs clear. October 8 : Abdomen 
distended, patient dull. October 13 : Right lung (lower) 
shows about same signs as before. October 25 : Epi- 
didymis on left side swollen, hard, and nodular. Novem- 
ber 16 : Diazo reaction again appears ; had been absent 
for several days. November 27 : Average temperature 



January 8, 19061 
Vol. XI, No. 1 J 



TUBERCULOSIS OF THE THORACIC DUCT 



(AMBKiCAir Medicine 21 



for last 14 days, 102° to 103° ; very little expectoration. 
No tubercle bacilli found. Contrast between bases of 
lungs as regards intensity of sounds ; in front below 
fourth rib on right side rales, tactile fremitus present. 
November 28 : Patient has been delirious, picks at bed- 
clothes ; pupils equal. November 29 : Pupils unequal ; 
left medium-sized, right moderately dilated; no evi- 
dence of hemiplegia. November 30 : Blood — reds, 
4,695,000. Urine — no albumin, no sugar, distinct diazo. 
White corpuscles, 10,000 ; hemoglobin, 8o fc. Novem- 
ber 30 (8 p.m.) : Pupils nearly equal ; corneal reflex on left 
side sluggish ; left pupil a little more active than right. 
Left arm almost motionless ; right arm moved volun- 
tarily ; left arm drops as if paralj'zed ; right leg resists 
flexion and extension ; left leg drops loosely. Patellar 
reflex small on both sides, more marked on left. Face 
symmetric. Patient unconscious, sank and died in early 
hours of morning of December 1, 1891. 

Anatomic Diagnosis: Tuberculosis of left testicle 
and epididymis or cord, seminal vesicles and prostate ; 
tuberculosis of abdominal glands and intestine (ulcers), 
and cerebral and spinal meninges ; miliary tuberculosis 
of lungs, liver, and kidneys ; tuberculosis of thoracic 
duct ; solitary tubercle of cerebellum. 

Abstract from Autopsy Notes : Lungs and heart re- 
moved in mass. Posterior mediastinal glands are en- 
larged and filled with easeous areas and miliary tuber- 
cles ; in upper portion of mediastinum there is a lymph- 
atic vessel size of 2 mm. in diameter, which can be 
traced some distance. It occupies the posterior portion 
of the thoracic duct. In the course of this is a tubercu- 
lous mass which apparently is formed around the lumen 
of the vessel and on section a lumen can be demonstrated. 
Owing to the general adhesions it is not possible to say 
whether this be a small vein or the thoracic duct. 
Pleura} over both lungs are enormously thickened ; filled 
with a caseous material ; along posterior edge of the 
right lung, just alongside of aorta, there is a distinct 
ridge-like projection which can be followed for some 
distance along lung and around its upper border. Both 
lungs on section contain numerous areas of miliary 
tubercles and there is here and there slightly peribron- 
chial tuberculosis which in a few places has begun to 
break down. The bronchi in thase places being dilated 
their wall is caseous and the caseous material extends 
in to the substance of the lungs*. 

Case XV.— Male, aged 20, admitted to Johns Hop- 
kins Hospital. 

Autopsy No. 1888. 

Anatomic Diagnosis : Acute miliary tuberculosis ; 
tuberculosis of the mesenteric and retroperitoneal lymph- 
glands ; tuberculous peritonitis with adhesions ; tuber- 
culosis of the thoracic duct ; miliary tuberculosis of the 
lungs, liver, spleen, kidneys, stomach, intestines, and 
cerebral pia mater ; diffuse tuberculous meningitis, lim- 
ited to the spinal cord. 

Abstract of Autopsy Notes : The lymph-glands in 
the retroperitoneal tissue in the neighborhood of the 
pancreas and on either side of the aorta are enlarged, 
often 1.5 cm. to 2 cm. in length, firm, and grayish on 
section, and at times partially caseous. The largest con- 
sists of a number of glands matted together and is 
3.5 mm. across, and situated at the hilum of the left 
kidney. The glands at the base of the mesentery are 
similarly enlarged. The lymphatic glands at the level 
of the bifurcation of the trachea and at the base of the 
neck are enlarged and contain gray, at times opaque 
areas. 

ThoradG Duct. — The thoracic duct where it lies to 
the right of the aorta just above the diaphragm is repre- 
sented by an irregular nodular cord at one point where 
there is a deviation .5 cm. across; on section through 
this point of maximum dilation the lumen is found to 
be wholly obliterated, its wall indurated, and in the 
center is an opaque caseous substance. Below this 
point the duct dissected out is found to branch ; branches 



are conspicuous but are not dilated. Just behind and to 
the left of the aorta, the duct is represented by a cord 
about 2 mm. in diameter. Its walls are thick, grayish- 
white in color and there occur nodules of the appearance 
of tubercles about 1 mm. across, seen somewhat indis- 
tinctly upon the surface. The orifice of the duct where 
it enters the external jugular vein is patent and admits 
a probe, passes from inside the duct into the vein. 

Case XVI.— Autopsy No. 1174: Dr. Flexner. 

Anatomic Diagnosis: Tuberculosis of lymphatic 
glands, generalized miliary tuberculosis (acute) with 
serofibrinous peritonitis and splenitis ; chronic tubercu- 
losis of peritoneal cavity as well as acute ; acute splenic 
tumor; infarction of spleen; tuberculosis of thoracic duct. 

The thoracic duct is opened and what seem to be 
minute tubercles are seen beneath the serosa. 

Case XVII.— Male, aged 45, colored, admitted to 
Pennsylvania Hospital October 4, 1903, in delirium. 
Clinical diagnosis, meningitis. 

Autopsy October 14, No. 467. 

Anatomic Diagnosis : General acute miliary tubercu- 
losis ; chronic tuberculosis and caseation of prostate and 
seminal vesicles ; thrombosis of left vesicular veins 
(tubercles in section) ; chronic apical pulmonary tubercu- 
losis ; tuberculosis of meninges; tuberculous ulcers of 
ileum ; chronic tuberculosis of adrenals. 

Thoracic duct, normal. 

Case XVIII.— Male, aged 19, colored, admitted to 
Pennsylvania Hospital February 23, 1903. Since August, 
1902, for last seven months, not feeling well ; laid up 
three weeks ago. Death in nine months. 

Autopsy No. 395. 

Anatomic Diagnosis : Subacute generalized tubercu- 
losis ; tuberculous bronchopneumonia with cavity forma- 
tion ; tuberculosis of left pleura and of bronchial lymph- 
glands. 

Thoracic duct, normal. 

Case XIX.— Male, aged 20, white, admitted to Penn- 
sylvania Hospital April 27, 1904 ; was in hospital from 
February 22, 1904, to March 26, 1904, with questionable 
pleural effusipn. Worked until three days before admis- 
sion. Death on August 1, with clinical diagnosis of 
tuberculous peritonitis. 

Autopsy August 2, 1904, No. 594. 

Anatomic Diagnosis : Generalized tuberculosis with 
caseous nodules in lung, spleen, liver, and kidney; 
caseation of lymphatic glands ; tuberculosis of per- 
itoneum. 

Thoracic duct, normal. 

Case XX. — Female, white, aged 13, admitted to 
Pennsylvania Hospital March 15, 1904. Laparotomy a 
year ago for tuberculous peritonitis. Admitted to hos- 
pital with this diagnosis, for which a second operation 
was performed. Death April 13. 

Autopsy No. 547. 

Anatomic Diagnosis : Unhealed old laparotomy ; 
tuberculosis of mesenteric retroperitoneal and cervical 
lymph-nodes ; tuberculosis of peritoneum ; perforation 
of intestines ; tuberculosis of spleen, intestines, and 
lungs ; fatty degeneration of liver ; anemia of all organs. 

Thoracic dz/£t, normal. 

Case XXL— Male, white, aged 40, admitted to Penn- 
sylvania Hospital October 10, 1904 ; clinical diagnosis, 
typhoid fever, with meningitis. Death, October 14. 

Autopsy October 15, No. 617. 

Anatomic Diagnosis : General acute miliary tubercu- 
losis ; chronic tuberculosis of left apex ; tuberculous 
ulceration of intestines ; tuberculous meningitis ; gen- 
eralized lymphatic tuberculosis. 

Thoracic duct, a little thick ; no definite tubercles. 
No tubercle bacilli in fluid from duct. 

Case XXII.— Female, aged 53, admitted to Pennsyl- 
vania Hospital November 22, 1904 ; sick three months; 
loss of weight ; no definite signs detected in chest, some 
fever. Meningeal symptoms. Clinical diagnosis, tuber- 
culous meningitis. 



22 Ambkican Medicine] 



TUBERCULOSIS OF THE THORACIC DUCT 



C January 6, 1906 
Vol. XI, No. 1 



Autopsy December 4, No. 631. 

Anatomic Diagnosis : General acute miliary tubercu- 
losis ; chronic pulmonary tuberculosis, with cavity for- 
mation ; tuberculosis of uterus ; tuberculous peritonitis ; 
rupture of intestines, with acute fibrinopurulent per- 
itonitis ; tuberculous ulceration of intestines. 

Thoracic duel, normal. 

Case XXIII. —Male, aged 19, white, admitted Octo- 
ber 25, 1904, to the Pennsylvania Hospital. Malaise for 
ten days ; thought at first to be typhoid, later tubercu- 
lous peritonitis; operation November 19, fecal fistula. 
Death, January 10, 1905. 

Autopsy January 10, No. 645. 

Anatomic Diagnosis : Generalized tuberculosis, sub- 
acute ; tubercles conglomerate and fairly large in spleen 
and liver ; chronic pulmonary tuberculosis ; tuberculous 
peritonitis ; laparotomy. 

Thoracic duct, normal. Smears show no tubercle 
bacilli. 

Case XXIV.— Male, aged 21, colored, admitted to 
Pennsylvania Hospital February 8, 1905; sick seven 
days ; operation for appendicitis. Death, February 21. 

Autopsy No. 668. 

Anatomic Diagnosis : Chronic tuberculosis of lungs 
with cavity formation ; tuberculosis of peritoneum with 
acute purulent peritonitis ; extensive tuberculous ulcera- 
tion of intestines ; appendectomy ; tuberculosis of mesen- 
teric lymph-nodes ; cloudy swelling of liver and kidneys. 

Thoracic duct dissected out to entrance into subclavian 
vein. It is normal. No smears from duct. 

Case XXV.— Female, white, aged 13, admitted to 
Pennsylvania Hospital February 16, 1905 ; sick since 
December 10, 1904, symptoms of meningitis ; fever while 
in hospital. Death, February 25. 

Autopsy February 26, No. 671. 

Anatomic Diagnosis : Generalized tuberculosis, sub- 
acute ; chronic tuberculosis of bronchial lymph-nodes ; 
partial consolidation of right lung ; bronchiectatic cav- 
ities in left lung ; localized tuberculous peritonitis; tuber- 
culous meningitis ; tuberculous ulceration of intestines. 

Thoracic duct, normal. 

Case XXVI. — Male, aged 66, admitted to Pennsyl- 
vania Hospital August 7, 1904; sick for four months ; 
clinical diagnosis of tuberculosis of lungs. 

Autopsy August 31, No. 600. 

Anatomic Diagnosis: General acute miliary tuber- 
culosis ; acute tuberculosis of pleurae and peritoneum ; 
chronic tuberculosis of mesenteric lymph-nodes and of 
left lung ; cloudy swelling of liver ; acute splenic tumor ; 
chronic diffuse nephritis ; mesenteric lymph-glands size 
of man's fist, caseous. 

Thoracic duct, normal ; no tubercle bacilli found in 
smears from fluid. 

Case XXVII. — Male, aged 25, colored, admitted to 
Pennsylvania Hospital July 22, 1905, complaining of 
abdominal soreness and distention. This was noticed a 
few days before admission. There has been a chill and 
some vomiting. Physical examination showed some 
distention of abdomen with general tenderness, but noth- 
ing of great importance is noted in the remainder of the 
examination. During the course of the illness a left- 
sided pleurisy developed which was relieved by tapping. 
Masses could be felt in the abdomen. There was gradual 
emaciation with an irregular fever, and the patient died 
on September 9. 

Autopsy September 11, No. 763. 

Anatomic Diagnosis : Tuberculosis of peritoneum ; 
tubercles in lung, spleen, liver, and right kidney ; tuber- 
culosis of pleurse ; congestion and cloudy swelling of 
kidneys. 

The peritoneum is massed in caseous material. Caseous 
tubercles varying from 1 mm. to 3 mm. in diameter are 
scattered irregularly through the lungs, spleen, liver, and 
right kidney. Sections through the spleen and liver 
show sparsely scattered small areas of caseation. 

Thoracic duct is thin and delicate throughout. 



Case XXVIII. — Male, aged 48, negro, admitted to 
Pennsylvania Hospital May 31, 1905. Except for a left- 
sided pneumonia, which the patient says he has had 
twice, there is nothing of importance in his past history. 
In March, 1905, he had a chill, followed by fever, cough, 
and severe headache. Since then he has been in poor 
health. Has had fever, continual cough, and occasional 
sweats. Examination showed poor expansion on both 
sides of chest, with increased vocal fremitus below right 
clavicle, where there is dulness and bronchial breathing 
without rales. Below left clavicle, fremitus is increased, 
there is decreased resonance, bronchial breathing, and 
rales. Posteriorly there is dulness along left side, with 
some suppression of breath sounds and decreased vocal 
fremitus. The patient gradually became worse. There 
was much expectoration. Emaciation was rapid. The 
temperature varied usually between 100° and 102° or 
103°. On June 16, tubercle bacilli were found in the 
sputum. The pulmonary signs increased in severity. 
During the illness there were several intestinal hemor- 
rhages. Finally, on June 21, the patient developed signs _ 
of meningitis and died on June 24. 'M 

Autopsy June 25, No. 730. ■ 

Anatomic Diagnosis : Chronic tuberculosis of apices 
of lungs; tuberculosis ofpleurte, pericardium, and peri- 
toneum ; tuberculous ulceration of intestines ; tubercu- 
losis of- cerebral meninges ; tuberculosis of spleen ; 
cloudy swelling of liver and kidneys. 

Thoracic duct is somewhat dilated and presents some- 
what thickened but smooth walls. There are no tuber- 
cles. 

Case XXIX. — Male, aged 20, white, admitted to 
Pennsylvania Hospital April 4, 1905. The patient is 
said to have been sick for eight days with fever, head- 
ache, pain in stomach, and cough. On examination, the 
patient is found to have rales over both sides of chest ; 
the abdomen is tender and distended but no other 
marked abnormalities found. The pulmonary symp- 
toms increased, rales became more numerous and there 
was much sputum in which tubercle bacilli were found. 
Emaciation was marked and the temperature ran a very 
irregular course varying often 4° to 5° in a day. The 
patient finally died on May 23, 1905. 

Autopsy May 24, No. 712. 

Anatomic Diagnosis : Tuberculosis of lungs ; caseous 
pneumonia of upper right lobe ; multiple bronchiectatic 
cavities of left lung ; tuberculosis of pleurse ; parietal 
thrombus on wall of pulmonary artery at pulmonary 
orifice ; thrombosis of right femoral vein ; multiple in- 
farctions of spleen ; congestion of spleen and liver ; 
cloudy swelling of kidneys ; tuberculous ulceration of 
intestines. Sections through the myocardium, spleen, 
liver, and kidneys showed no tubercles in these organs. 

Thoracic duct, normal. 

Case XXX. — Acute miliary tuberculosis. Walls of 
thoracic duct free from tubercles. Many tubercle bacilli 
found in smears from fluid in duct. 

Of these 30 cases, 19 were typic instances of general- 
alized acute miliary tuberculosis, in which minute 
tubercles were scattered in enormous numbers through 
most of the organs of the body. When histories could 
be obtained the course of the disease was rapid, lasting 
usually from 2 to 12 weeks. The thoracic duct in 14 of 
the 19 cases showed a more or less extensive tubercu- 
losis, usually with caseous nodules,while in one instance, 
though there was no tuberculosis of the wall of the 
vessel, many tubercle bacilli were found in smears from 
the duct lymph. In one of the four remaining cases in 
which the duct was normal there was a primary tuber- 
culosis of the epididymis and testicle, with organized 
thrombi in the vesical veins, containing caseous masses 
and tubercles. 



January 6, 19061 
Vol. XI, No. 1 J 



TUBERCULOSIS OF THE THORACIC DUCT 



lAMEBICAN MKDIOINIT 23 



In eight instances the generalized process was sub- 
acute or chronic. Large tubercles or caseous masses 
were scattered in small numbers through the various 
organs, while during life the course of the disease was 
protracted, lasting from three to nine months. In only 
two of these cases was there a tuberculosis of the thoracic 
duct. In both instances the tubercles were small and 
occurred sparingly, but in one a few tubercle bacilli 
were found in smears from the fluid of the duct. 

Finally, in three instances, the tuberculosis was of a 
chronic tj'pe and confined to the lungs and peritoneum. 
In all of these cases the thoracic duct was normal. 

It is difficult to draw a line between the cases of 
acute and subacute generalized tuberculosis, but between 
the extremes of the two types a distinction can certainly 
be made. The cases with which we had to deal were 
fairly distinctive. Of the 27 cases of tuberculosis in 
which the proceas was more or less generalized, 17, or 
almost 63^, showed tuberculosis of the thoracic duct, 
or, as in one instance, tubercle bacilli in the lymph from 
the duct without lesions of its walls. Of the acute cases 
in over 79 'ft, the duct was affected or contained tubercle 
bacilli. 

The type of lesion in the duct varied considerably. 
Sometimes there was a single large caseous nodule usu- 
ally near the receptaculum or about the arch of the 
aorta, with small tubercles over the intima of the vessel 
above and below it ; sometimes several caseous nodules 
were scattered through the duct, while occasionally the 
walls of the lymphatic were simply seeded with small 
tubercles. In every instance the lymph-nodes of the 
mesentery, retroperitoneum, posterior mediastinum, or 
bronchial regions were the seat of a chronic tuberculosis. 
At times several groups of glands were aff'ected, but 
more often only one group, and rarely only one or two 
glands, as in Case VII. 

Often the lesion in the duct appeared almost as old as 
that in the neighboring lymph-nodes and was in close 
association with it, though a direct extension of the 
process from the gland to the wall of the duct was never 
seen. In at least two instances the caseation of a small 
group of lymph-nodes and of the thoracic* duct wall 
were the only foci of .chronic disease which could be 
found in the body. 

This intimate association between the lesions of the 
lymph-nodes and of the duct which existed so often, 
leads orie to suppose that the infection travels directly 
from the lymph-nodes through the lymphatics to the 
thoracic duct. It is well known, through the experi- 
ments of Nicolas and Descos," Arloing," Ravenel,-" and 
others, that tubercle bacilli when fed to dogs may pass 
directly through the intestinal wall without producing 
perceptible lesions, travel to the mesenteric lymph- 
nodes and rapidly enter the thoracic duct where they 
may be demonstrated soon after the feeding. The 
method of infection ascending from foci of disease in the 
abdomen or travelling from lymph-nodes elsewhere in 
the body through the blood to the lungs, has recently 
received much study. Harbitz " has lately reviewed the 
literature upon this subject. 

Apparently the same series of events takes place in 
these cases of thoracic duct infection. In a certain num- 



ber of instances tubercle bacilli are carried to the thoracic 
duct from adjacent tuberculous lymph-nodes. Here 
they lodge and produce a localized subacute or chronic 
lesion. Sooner or later this nodule breaks down and 
enormous numbers of tubercle bacilli, as may be demon- 
strated by smears of the lymph, are liberated and swept 
by the lymph into the general circulation, producing an 
acute and rapidly fatal general tuberculosis. Even if a 
large tributary to the duct is the seat of a caseous tuber- 
culosis, the same series of events may follow, and, as in 
one of our series of cases, tubercle bacilli would be swept 
into the lymph of the duct without of necessity produc- 
ing changes in its walls, or, as has been frequently 
noted, only giving rise to a miliary tuberculosis of the 
duct itself. It has frequently been shown that neither 
during life nor at autopsy can large numbers of tubercle 
bacilli be demonstrated in smears from the blood, so that 
the mere presence of great numbers of tubercle bacilli in 
the lymph from the thoracic duct suggests that they are 
disseminated from a reservoir near by. 

Of special interest are the cases of subacute general- 
ized tuberculosis with lesions in the duct. In such cases 
it seems probable that from tuberculous lymph-nodes, 
tributaries to the duct, and small foci of tuberculosis 
in the duct itself, a few tubercle bacilli may from time 
to time be swept by the lymph into the circulation and 
scattered to different parts of the body, producing a 
chronic general infection instead of the rapidly over- 
whelming type of acute infection. 

Our series of cases suggests, therefore, that the thoracic 
duct is of great importance as a channel for the spread of 
tubercle bacilli through the body from the various 
groups of lymph-nodes. Undoubtedly, tuberculosis of 
the veins and arteries is also to be reckoned as a factor 
in the rapid dissemination of tubercle bacilli through 
the body, but is subsidiary in importance to tuberculosis 
of the thoracic duct and its tributaries. 

From a study of these cases the following conclusions 
may be drawn : 

Tuberculosis of the thoracic duct is of great frequency 
in cases of acute generalized tuberculosis. The lesions 
in the duct from which tubercle bacilli are swept in 
great numbers through the lymph to the general circu- 
lation form the starting point for the generalized acute 
process. In certain cases of acute generalized tubercu- 
losis, tubercle bacilli may be found in the lymph from 
the duct, though the duct itself is not the seat of tuber- 
culosis. In a small percentage of cases of subacute 
generalized tuberculosis the duct may also be aff'ected. 

BIBLIOGRAPHY. 

• Medical Records and Researches, 1798, Vol. i, p. 86. 

2 Arch. Gen. de Med., 1824, T. vi, p. 508. 

•Berlin klin. Woch., 1877, No. 4(j, p. 073. 

•51 Natur forsher Versamailung 1878, quoted from Virch. 
Arch., 1882, Bd. 88, p. 307. 

5 Virch. Arch., 1882, Bd. 88, p. 111. 

« Wiener med. Woch., 1884, No. 39, p. 50. 

' Mit au8 der Kaiserlich Gesundheitsamte, 1884, Bd. 2, p. 24. 

8 Deut. med. Woch., 188;!, No. 24, p. 349. 

•Diss. Heidelberg, 1889. 
"Virch. Arch., 1877, Bd. 108, p. 221. 
" Quoted from Benda. 

" Verhandl. d. Berl. med. Gesellsehaft, 1809, Bd. xxx, ii, 
p. 15:j. 

"Verhandl. d. Berl. med. Gesellsehaft, 1889, Bd. xxx, ii, 
p. 259. 

"Virch. Arch., 1897, Bd. 149, p. 65. 



24 Amkbican MkdicinbI 



FEEDING THE BABY 



rJAKUABY 6, 1906 

LVOI. XI, No. 1 



" Deut. med. Woch., 1897, No. 53, p. 841. 

" " " " " Nos. 48, 49, pp. 761, 780. 

" Virch. Arch., 1905, Bd. 79, p. 28;J. 

"Centr. f. Back, u Parasit., 1902, Bd. xxxii, p. 300. 

" Presse Med., 1903, T. i. No. 29, p. 298. 

«» Jour, of Med. Research, 1903, Vol. x, p. 460. 

" Jour, of Infect. Diseases, 1905, Vol. li, p. 143. 



FEEDING THE BABY.' 

BY 

WARD B. HOAG, M.D., 
of New York. 

Ideals, with a proper conception of "the ideal," are 
essential to success in any undertaking. The best in 
nature cannot be improved upon, and may well be 
studied thoroughly in any attempt to establish an ideal. 

In feeding the baby, our greatest success results from 
having him at his mother's breast, when it is of the best. 
That should be our ideal. Unfortunately, too often the 
breast is not of the best ; and then our endeavor should 
be either so to modify the breast that it accords with the 
proper demands of the child, or to secure a substitute 
that serves the same purpose. 

Generally speaking, the well-fed baby is good- 
natured and comfortable, and each week shows a certain 
amount of growth. This rule has sufiScient exceptions, 
such as make it always our duty to inquire as to the 
nourishment the child is getting, and also to examine 
him, to ascertain whether the increase in weight is of a 
healthy character. 

Nature is so inexorable that if we violate her de- 
mands for any length of time we must pay the penalty. 
If we feed a baby on 1 % of fat and \fcot proteid, when 
he should be getting Sfo or 4^ of fat and 1J% of pro- 
teid, we have a right to expect that he will show evi- 
dences of malnutrition. Frequently, a baby fed on 
condensed milk is goodnatured and plump, and is held 
up to physician and admiring friends as the model 
baby. When we investigate the amount of nutrition he 
is getting, and then compare it with what nature intended 
him to have, do we wonder he is rachitic ? Right here 
let us remember that enlarged epiphyses, crooked shafts 
of bones, and late dentition, are not the only manifesta- 
tations of rickets ; we may also have flabby, relaxed 
muscles, and the unstable nervous system. One part of 
"Eagle Brand" condensed milk to six parts of water 
gives .99 fat, 1.20 of proteid, and 7.23 of sugar. The 
baby is usually fed a teaspoonful of condensed milk to 
4 oz. or 6 oz. of water — a fifth to an eighth of the nutri- 
tion stated above. Figure that out, if you will, and 
then compare the percentages with those which any 
baby is entitled to, and you will wonder that the child 
lives at all. 

Feeding the baby is too often looked upon as a 
simple, mechanical process. We fill the stomach with 
anything the child will take, or, if he be old enough to 
express a preference, with anything he may desire. 
This principle will lead us to overfeed (overstuff) more 
often than to underfeed ; but it will just as surely result 
in malnutrition and disease. 

There is no question but that the mother's milk, 
where it exists, is the natural food for her baby ; but 

1 Read before the West End Medical Society, New York 
City, April, 1905. 



it is equally certain that there are many babies who do 
badly at the breast. The personal equation, as expressed 
by each infant's power to a.ssimilate, enters into consid- 
eration almost as much in the breast-fed baby as it does 
in the artificially fed. We frequently see a baby starv- 
ing on a good breast of milk, one in which the fat and 
proteids are within normal limitations. Here the baby's 
ability to assimilate is below normal, and the milk must 
be brought down to his digestive capacity. Again, a 
baby fails on a breast too rich in fat or proteid, one or 
both. Here again we must try and reduce the food to 
his requirements. If both fat and proteid are markedly 
deficient in the mother's milk, fat 1 ^ or 1.5^, and pro- 
teid .5fc to 1^, there is little probability of being able 
to improve the milk so that it will contain sufficient 
nourishment, and it is best to wean the baby or get a 
suitable wet nurse. Sugar in mother's milk is fairly 
constant as regards its amount, varying very little from 
7 ft>. It is well tolerated by the infant and seldom is to 
be regarded as a factor in the adaptation of the milk to 
the baby's requirements or digestive capacity. Fat and 
proteid vary under certain conditions, dependent upon 
the temperament, diet and occupation of the mother. 

By means of the lactometer and a graduated cylin- 
der, we can form a very accurate idea of the amount of 
fat and proteid present in the milk. The specimen to 
be examined should be taken after the first half ounce 
has been discarded from the breast, thus providing a 
specimen of average richness ; the first drawn being 
specially thin, and the last of more than average rich- 
ness. 

Average good milk shows a specific gravity between 
1,028 and 1,032. If the specific gravity is much above 
1,032, it would indicate a high proteid, or an average 
proteid and a low fat ; and if below 1,028, low proteid 
with possibly high fat. The fat is accurately determined 
by allowing the cream to rise for 24 hours in the cylin- 
der, graduated to hundredths. The proportion of fat in 
the cream is as 3 is to 5 (f). If we have 8fo cream, the 
fat will be I of 8 = 4J ^ . Aside from an idiosyncrasy 
on the part of the baby, we can form a fairly definite 
idea of the nature of the milk from the history of the 
baby. Small, frequent, irritating, intensely yellow, or 
sometimes green stools ; sour eructations from the 
stomach, almost always indicate excessive fat. The 
foregoing conditions existing, there is certainly an excess 
so far as the baby's capacity is concerned. Colic, consti- 
pation, curds in the stool mean excessive proteid. 

If our nursing mother has a fair quantity of milk, 
but it is moderately deficient or excessive in either fat or 
proteid, we can do much to correct the discrepancy. 
If the milk is too rich, both fat and proteid bjeing high, 
cut ofi" alcohol, more or less decrease the nitrogenous 
food, especially cutting out red meats, and increase 
the mother's exercise, having it taken out of doors. 
If the milk is moderately deficient in fat and pro- 
teid, exactly the opposite conditions to the foregoing 
as regards alcohol, diet and exercise are to be advised. 
If, in the cases in which the milk is too rich, we are un- 
able to reduce it by diet and exercise to the baby's ca- 
pacity, we can modify the milk by giving before or dur- 
ing nursing a half ounce, more or less, of boiled water. 



January 6. 19061 
Vol. XI, No. 1 J 



FEEDING THE BABY 



AMKBICAN MbDICINB 25 



If the proteid is especially high, 5 or 10 drops of elixir 
laetopeptin added to the water serves a good purpose. 
When the milk is deficient only in fat, and the baby is 
inclined to constipation, a half to one teaspoonful of 
cream can be given before one or more nursings each 
day. It is interesting what can be done with a mother's 
breast milk, and with her baby, by using a little intel- 
ligence. 

Not long since I saw a baby a month old weighing 
6 pounds 10 ounces, who at birth weighed 14 pounds 2 
ounces. The baby was nursed at the breast every hour 
as long as he could be induced to draw. Either while at 
the breast, or soon after being taken away, he would 
vomit about all he had taken. He was sour, and his 
stools were frequent and very irritating. Because of the 
rapid emaciation of the baby, it was taken for granted 
that the mother's milk was of a poor quality, and every 
endeavor was being maintained to make it better. The 
mother was not allowed any exercise whatever out of 
dooi-s, though she had been about the house over two 
weeks. She had a glass of malt extract with each meal, 
and was encouraged to take as much meat and as many 
eggs as possible each day. A specimen of her breast 
milk showed 6^ of fat, which told the whole story. The 
mother's diet was changed, she was sent out of doors for 
an hour at two intervals in the day, the baby's stomach 
was washed once each day, and before each nursing he 
was given 1 oz. of a 3 ^ sugar water, after which he was 
allowed to nurse five minutes. The nursings were at 
two-hour intervals during the day and at four-hour at 
night. Under these regulations the vomiting stopped 
and the child almost at once began to gain. The 
mother's milk was soon reduced to 4/c fat and the water 
given before nursing was gradually withdrawn. 

The proteid is apt to cause more trouble than the fat, 
80 far as colic is concerned ; but here again much can be 
done by diet and exercise on the part of the mother. We 
can also modify the milk as it goes into the stomach by 
giving water before and during the nursing. 

Bottle Feeding. — With the artificially fed baby, if the 
mother or the nurse is ordinarily intelligent, and the 
child has not already had his digestive apparatus upset, 
we ought easily be able to provide him with nourish- 
ment suited to his demands and capabilities of assimila- 
tion. Good dairy milk, not "one cow's milk," should 
form the basis of our food. In changing cows' milk for 
the babies' use, "adapting the milk" is a much better 
term than " modifying." Modify simply means change, 
while adapt means to fit, or suit ; a conforming to a 
personal requirement. 

Set formulas for feeding the young baby are an 
abomination, and inclined to cause more trouble than 
assistance. They tend to oblige the baby to conform to 
the rule, whereas we should all know that it is neces- 
sary to make the rule for the baby. Formulas can be 
followed successfully in only a minority of cases. At 
the present time an enterprising pharmaceutical house 
is engaged In distributing among physicians cards on 
which are printed formulas for feeding the baby from 
birth. We are told that the formulas are in accord with 
those contained in the book of a well-known New York 
pediatrist. According to these cards, we are to start the 
newborn baby on i.bfc fat. I doubt whether three out 
of ten babies could assimilate that strength of fat at 
birth. What about the other seven? If we are to 



formulate any rule at all for feeding babies, it should be 
for the seven, rather than for the three. Our chief 
endeavor in starting to feed the baby should be to give 
what we feel is less than the baby can assimilate. We 
can easily and quickly increase the strength of food to 
reasonable percentages if the baby is able to care for the 
weaker food. It is a matter of clinical experience, 
regardless of the general strength of the food, that babies 
thrive best when our adapted milk is prepared with the 
idea of keeping the relative proportions of sugar, fat 
and proteid about the same as exist in mothers' milk — 
sugar, twice as much as fat ; and fat, two or two and a 
half times as much as proteid. 

Cereal Gruels. — There seems to be a great diversity of 
opinion, even at the present day, regarding the use of 
cereal gruels as diluents, or as a substitute for the regu- 
lar milk food, in case of a gastrointestinal infection. It 
is a clinical fact that in the great majority of cases babies 
do better when a well-cooked gruel is used as a diluent 
than if plain water is used. This is the experience of 
practically all good observers. Still, not long since, a 
prominent New York pediatrist closed his part of a dis- 
cussion by stating that "any medical man who advo- 
cates the use of cereal gruels in infants under 6 months 
of age, in health or in disease, should be sent back to 
the medical school to study physiology." My only crit- 
icism regarding this gentleman's ideas must be that, 
occasionally, people go through this world with their 
eyes wide open, and still they will not see. 

If ordinary oatmeal, pearl barley or rice are used for 
the gruel, they should be boiled for three hours. Patent 
barley, groats, or wheat flour in the form of imperial 
granum, need to be cooked not more than 20 minutes. 
For the youngest child, one or two teaspoonfuls of the 
cereal to the pint of water is used. After 6 months of 
age the cereal may be increased to one or even two 
tablespoonfuls to the pint. If a small amount of dex- 
trin be added to the gruel, when lukewarm, the gruel is 
more easily assimilated, and a stronger gruel can be 
used. I usually use cereo, in the proportion of a tea- 
spoonful to a pint of gruel. Gruels, when added to 
milk, certainly make a finer division of the curd ; they 
also add a definite and substantial amount of nourish- 
ment. W. H. Jordan, of the New York Agricultural 
Station, gives the following as the approximate percent- 
ages of nutritional elements : 





Pearl 


Barley 


Wheat 


Rolled 




Barley. 


Floor. 


Flour. 


Oats. 




•a 


1^' 
is « 


•o 




•a 


U 


•a 


ki 




S 


« 


Hg 


S. 


2* 


0) 


ss 




a 


«« 


s 


'S.^ 


s 


cSQ 


s 


03*0 




a. 


u 


CM 


o 


Oi 


O 


CM 


€> 


% oz. to the pint of 




















.07 


.67 


.097 


1.04 


.166 


1.08 


.181 


.83 







Cane Sugar or Milk Sugar. — In the thousands of 
babies fed at the Babies' Hospital clinic, it is a rare thing 
for us to use milk sugar. Our infants do well on granu- 
lated sugar too. Cane sugar is much cheaper than the 
milk sugar, and less apt to be adulterated. As good an 
obseryer as Dr. Brush refuses to supply his milk for 
infant-feeding if milk sugar is used in preparing the 



26 Amkbican Mbuicine; 



FEEDING THE BABY 



[ 



Jakuaby 6, 1906 
Vol.. XI, No. 1 



food. He claims that milk sugar, when added to the 
food, is a prominent cause of contamination. 

Working Formulas. — In the preparation of cows' milk 
for infant food there are a number of schemes recom- 
mended. It is well to select one that seems fairly 
simple, and at the same time fairly accurate. Which- 
ever the scheme adopted, we must keep constantly in 
mind certain approximate facts : 

Mothers' milk contains 3.5^ to Afc fat; 1.5 /o pro- 
teid ; 7/c sugar. Proteid of mothers' milk largely lact- 
albumin, is easy of digestion. Little casein. 

Cojvs' milkifc fat; 4fo proteid; 4^ sugar. Proteid 
of cows' milk largely casein, difficult of digestion by in- 
fants. Little lactalbumin. 

Gravity cream (milk standing from 6 to 8 hours at or 
below 60° F.) contains 16/o fat; 4^ proteid ; ifo sugar. 

In using gravity cream, all the cream should be re- 
moved from the bottle and mixed. This gives us a uni- 
form strength. 

The scheme I will present is an old one. The basis 
of our calculation is always the pint, 16 ounces. Then, 
if we want more than the 16 ounces of food during the 
24 hours, multiply the proportions used in making the 
16 ounces by IJ, 2, 2J or 3, depending on the number of 
ounces of food we need. 






Fat. Proteid. Sugar. 



<'> Wafer, 15 ouScIs} = -25 -^ -^ (A clear milk) 

16 
(") MU^'^^ ^2 ouncesl 50 ..50 .50 (jS clear milk) 

16 

'"^' Water I °"°''®*|- = 2.00 2.00 2.00 (J clear milk) 



(IV) MHk,^^ ^6 ounces! _ ^j^ ^^ 1,50 (j ^^^^ ^,1^) 



^""^ ^^: 15 ouncis} = l-O" -^ -^^ ^^' °' 1«* «>•«»•»> 

16 
(VI) Cream, 1* ounces") 

Milk, 4 " > = 2.50 1.375 

Water, lOJ " J 

16 



1.375 (J milk, IJ X A 
of 16sS cream ) 



(One slightly rounded tablespoonful of granulated sugar equals 
approximately a half ounce.) 

Jounce sugar to 16 ounces (V ounces) = 1 In 32; approximately 

TOO ^^ "*• 

J ounce sugar {3^) added to No. 6 = 2.50 fat, IJ^ proteid ; 4J!« sugar ; 
approximately. 

This makes a food of fair nutritive strength, and one 
that closely maintains the relative proportions of fat, 
proteid, and sugar to be found in mothers' milk. 

Alkalies. — It is not necessary, nor advisable, to add 
an alkali regularly to the child's food. At the Babies' 
Hospital Clinic it is very exceptional for us to advise the 
use of lime water or sodium bicarbonate, and still our 
babies thrive. Certainly, if we have a good quality of 
well-kept milk there should be no excess of lactic acid 
before it enters the baby's stomach. If on general prin- 
ciples we add an alkali to the food, we inhibit the activ- 
ity of the stomach and at the same time place increased 
responsibilities on the intestines. For its proper devel- 
opment, the stomach demands an opportunity to work. 



Rather than to use alkalies, it seems to me we could 
better expend our energies in securing a better quality 
of milk, and having greater care taken in preparing and 
keeping the food. 

Sterilization or Pasteurization. — Whether we sterilize 
or pasteurize the milk depends upon the quality of milk 
and the time of year, as well as on the care we can be 
assured will be taken in preparing and keeping the food. 
If you have a careful, fairly intelligent mother, and a 
good supply of milk, except during the hottest weather 
of summer, it is unnecessary to pasteurize (heat to 167° 
F. for 30 minutes). If the milk supply or the mother's 
care is questionable, certainly we must pasteurize ; and 
if the weather is hot, sterilize (heat to 212° for 30 
minutes). Explicit direction should be given the 
mother regarding boiling, each day, of all utensils used 
in preparing the food. This will include the nursing 
bottles and the nipples. Of this one fact we may be 
certain, the less the milk is heated before it is given the 
baby the better it will nourish him. A condition of 
actual scurvy, the result of too much heat applied to the 
milk, is frequently observed. 

Difficult Feeding Cases. — The difficult feeding cases 
are usually manufactured ; babies have fairly good diges- 
tive capacities until they have been more or less ruined. 
Too strong food in the beginning, especially as regards 
proteid ; too much food at a nursing, and food too fre- 
quently given, are the principal causes leading up to 
difficult feeders. We have these cases every day at the 
babies' clinic. They did indifferently for a month or so on 
the mother's breast ; they had some colic and they vom- 
ited more or less ; they lost slightly in weight. At some 
one's suggestion they were taken from the breast, and, 
usually, were put on equal parte of cow's milk and water. 
This caused more colic and vomiting than the mother's 
milk ; and they then began the proprietary foods, going 
through the list, and finally they ended up with con- 
densed milk and marked evidences of malnutrition. We 
see the most of these babies when they are from 6 to 9 
months, weighing anywhere from 5 to 10 or 12 pounds — 
a third or a half as much as they should weigh. 

Where is the first mistake made on beginning to 
bottle feed under the above conditions ? In not washing 
out the stomach and cleaning out the intestines, and giv- 
ing the baby's stomach and intestines a rest for a few 
days, feeding only a weak sugar or dextrinized gruel 
mixture. Our next mistake is in starting with too much 
milk. Begin with as little as 2 oz. or 3 oz. of milk to 
the pint of food, adding 3^ or Afo of sugar; then in- 
crease the milk gradually, adding J oz. to 1 oz. of milk 
to the pint of food, as the baby shows he is able to care 
for it. Rarely we find a case in which the weak milk 
mixture causes discomfort, while if we radically increase 
the strength of the food, the baby cares for it comfort- 
ably. Southworth explains this by the relative excess of 
hydrochloric acid secreted by the stomach to the small 
amount of casein in the weak food, forming tough curds. 
When the casein is increased within reasonable limits, 
the same amount of acid would combine with the larger 
amount of casein to form softer and more digestible 
curds. Occasionally it is necessary to remove all the 
casein from the milk, giving only the soluble lactalbumin 



January 6, 1906T 
Vol. XI, No. 1 J 



PRIAPISM A SYMPTOM IN LEUKEMIA 



[Ambrican Medicine 27 



and a portion of the fat with the sugar. This, as whey, 
contains Ifo lactalbunain, 1% fat, and Afc sugar. 

QuantUy at Feeding. — The number of ounces of food 
at a feeding should always be considered, and definitely 
advised ; 1 oz. tp U oz. at birth are gradually increased, 
so that at three months of age, the baby is getting from 
3 oz. to 4 oz. From this on, to the eighth or tenth 
month, the number of ounces at a feeding corresponds 
fairly closely with the number of months of age. Too 
much food at a feeding means an overdistended stomach, 
and a train of indigestion symptoms hard to correct. 

Interval of Feeding. — The interval of feeding should 
never be less than two hours ; rather make it two and a 
half hours, if there is any disposition to vomit. By the 
third or fourth month the interval should be increased 
to three hours, and after the eighth or ninth month to 
three and a half or four hours. After the third or fourth 
month there should be no feeding between 10 at night 
and 6 in the morning. If, for a time, food is demanded, 
give a drink of plain water or sugar and water. 

Stomach Washing. — The difficulty of promoting 
assimilation of the food, and the growth of the baby, 
even though there be no vomiting, is markedly lessened 
by regular washing of the stomach each day. One 
stomach gavage is usually more effective than weeks of 
attempted medication. 

Condensed milk, particularly the unsweetened, is fre- 
quently a valuable temporary food. It is especially 
good when there is marked inability for casein diges- 
tion. "When constipation is a troublesome factor, and 
enough fat cannot be added to correct it, often a tea- 
spoonful of Mellin's food or malted milk to each feeding 
will prove effective. With a child five or six months 
old, a tablespoonful or less of orange juice a half hour 
before one or two feedings in the day is another excel- 
lent means to relieve constipation. Orange juice is 
usually greedily taken, and it not only relieves the con- 
stipation, but furnishes the child with an element of 
nutrition which promotes a normal metabolism often 
lacking in the artificially fed infant. 

In conclusion, I wish to express my appreciation for 
certain valuable suggestions contained in the writings 
and teachings of Drs. Kerley, Crandall, Chapin, Holt, 
and Southworth, regarding the subject we have just con- 
sidered. 



I 



PRIAPISM A SYMPTOM IN LEUKEMIA : REPORT 
OF CASE.' 

P. L. GUNCKEL, M.D., 
of Dayton, Ohio. 

The attention of the profession was first called to this 
peculiar symptom in connection with leukemia by 
Salzer, who, in 1879, reported an interesting case of pri- 
apism of six weeks' duration, and from his personal 
knowledge refers to eight other cases of leukemia in 
which priapism was the initial symptom. 

Since the publication of Salzer's case in 1879, one or 
more cases of this character have been reported yearly. 

> Read before Montgomery County, Ohio, Medical Associa- 
tion, May 2, 1902. 



Most all of the later works on practice at the present 
time include priapism as a more or less peculiar symp- 
tom of this disease. 

In April, a year ago, I treated a case of this kind, the 
report of which follows : 

Case. — C.' L. C; the patient was a tall, spare anemic 
man, aged 36 ; by occupation, an assembler, but he had 
worked at brass finishing for about five years previous 
to assembling. He was born and reared in Dayton, and 
was unmarried. 

Family History. — Father met death by an accident. 
He always had good health. Mother is living and in 
good health ; one sister living and in good health, and 
one sister dead of diphtheria. 

Previous History.— Daring childhood he had rheu- 
matism, measles, whoopingcough, and at the age of 12 he 
had malaria. Again, at the age of 25, he had an attack of 
malarial fever, which confined him to the house for 
about four weeks. He says he has never been well since 
this last attack of malaria, as a result of which he con- 
stantly complained of weakness. To relieve this weak- 
ness, he was constantly taking medicine. He has had 
gonorrhea a number of times and has had syphilis. He 
indulged in excessive venery, and would continue inter- 
course until a number of orgasms were expended before 
his insatiate appetite was appeased. Tuberculosis or 
alcoholism do not enter into the personal or family 
history. 

Present History. — There is present a profound anemia. 
Heart, lungs, liver, and kidneys are apparently normal. 
An enlarged and slightly tender spleen is present. Urine is 
free from albumin and sugar. Genitourinary organs : An 
abnormal, persistent, and painful erection of the penis, 
unattended with sexual desire, constituting a priapism. 
This condition had existed about 36 hours previous to my 
seeing the patient and had resisted the therapeutic efforts 
of two physicians before me. 

The patient gave a history of several attacks of 
priapism previous to this great and final one of 
several hours' duration, but these disappeared upon 
vigorous walking or working, thereby diverting his 
mind from the disagreeable condition. The attack 
previous to this one lasted 8 or 10 hours. The existence 
of the last priapism, which continued for about six 
weeks, so painful, persistent, and continuous, occurring 
in conjunction with a gradually enlarging spleen, is the 
subject to which I desire to call attention. 

In appearance the priapism did not differ essentially 
from an ordinary erection, except the penis was probably 
slightly enlarged at its base. 

The pain which this condition provoked was excru- 
ciating and almost unbearable, the penis standing erect at 
an angle of about 45°, and as rigid as is possible for an 
erection to be. Even the slightest touch upon the glans 
would bring forth a scream of pain from the patient. 
His suffering was so intense that it was necessary to 
keep him constantly under the influence of an opiate. 
The act of voiding urine, as one would naturally 
imagine, was attended with considerable difficulty. The 
act could only be accomplished by assuming a position 
similar to the knee-chest. 

I am confident that from the treatment which he re- 
ceived from me and those who subsequently treated him 
that every therapeutic agent for the relief of this peculiar 
condition was tried, together with phlebotomy and com- 
plete anesthesia under chloroform. This priapism con- 
tinued in its rigidity for about four weeks, after which 
time it gradually began to subside for the remaining two 
weeks of its existence to arise no more. 

For the following additional notes I am indebted to 
Dr. W. J. Conklin, who had charge of the patient dur- 
ing the last four months of his life, and who watched the 
progress of the disease with a great deal of interest. 



28 AMKtllcAN MEtotciurai 



FATAL HEMATEMESI8 



TJanuary 6, 1906 
Lvoi.. XI, No. 1 



While he did not keep detailed notes of the case, he 
kindly furnished me with the following data : 

Mr. C. came under his care after the disease had ex- 
isted about four months. He complained chiefly of 
weakness ; breathlessness on exertion, with an occasional 
sharp attack of dyspnea when at rest. Severe and nearly 
constant abdominal pain and diarrhea. There was no 
fever ; emaciation was marked. Physical examination 
disclosed profound anemia; a spleen that extended 
nearly to the navel and was sensitive to pressure. The 
lymph-nodes in the neck, axillas, inguinal, and femoral 
regions were enlarged. Heart slightly hypertrophied, 
the apex being in the mammary line. An anemic bruit 
was distinguishable, which extended into the carotids, 
and the second aortic sound was accentuated. Lungs 
normal. Urine free from albumin or sugar. There was 
a decided pufflness about the ankles and feet. Several 
blood-examinations and counts were made. The report 
of the microscopic findings were, unfortunately, mislaid 
and he can only give the results in a general way. The 
white corpuscles were enormously increased in number 
and nearly equaled the red, which were greatly reduced 
below normal. In addition to a large number of myelo- 
cytes and lymphocytes, there were many very large 
mononuclear leukocytes. The color of the blood was 
quite characteristic. To the naked eye it was so color- 
less in appearance as almost to verify the popular phrase 
of "blood turned to water." Diarrhea continued to be 
a prominent symptom, and not infrequently the dis- 
charges were largely of blood. 

Pain in the occiput, ringing in the ears, and breath- 
lessness with the abdominal symptoms were constant 
and marked. 

In view of the rather unusual beginning of the dis- 
ease. Dr. Conklin states it may be proper to add that 
there was a total extinction of sexual desire and power 
while the patient was under his care. 

Contrary to the usual ending in leukemia, the spleen 
during the last weeks of his illness was decreased mate- 
rially in size. 

He died of exhaustion about seven months after the 
appearance of the priapism. 

Now, the question naturally occurs to me and to 
others, why priapism should exist in the course of a leu- 
kemia the existence of which has never been satisfac- 
torily explained. 

It is evident, however, that the changes which take 
place in the corpuscular elements in leukemic blood con- 
duce to this condition, and the consequent leukocytosis 
produces certain changes in the bloodvessels that are 
concerned in the mechanism of an erection. Perhaps the 
most plausible explanation of the phenomenon advanced 
at the present time is, that priapism is due to a coagu- 
lation of blood into the bloodvessels, or possibly an infil- 
tration of blood into the nonstriated muscular fibers of 
the corpora cavernosum, thereby producing thrombi. 
The thrombi may occur also in the walls of the blood- 
vessels, producing what are known as parietal thrombi, 
which, by depositing in . the endothelial lining of the 
arteries during erection, prevent the returning tortuosity 
of the bloodvessels, which takes place in its passive 
state, the lengthening out and engorging of which con- 
stitutes the principalcause of a physiologic erection. 

It should be noted physiologically that the vascular 
arrangement of the penis differs from all other tissues in 
the body, inasmuch as the arteries do not simply branch 
and divide dichotomously as in other parts, but are 
arranged arborescently and become immediately 



tortuous and are distributed to the cavernous and spongy 
bodies. In these parts the arteries are large and tortuous 
and have unusually thick muscular coats and are con- 
nected with veins considerably larger than true capil- 
laries; the arteries being supported in addition by a 
strong, fibrous, network of trabeculas, which contain 
nonstriated muscular fibers, so that when the bloodves- 
sels become completely filled, the organ becomes enlarged 
and rigid. It is evident, therefore, that a normal erec- 
tion depends mainly upon the peculiar arrangement and 
construction of the bloodvessels and not a simple conges- 
tion or stasis of blood in the penis as probably may take 
place in some conditions, producing priapism. There 
are others who believe that the causation of priapism 
maybe found in irritation of the central nervous system, 
or by calcareous deposits along the course of the pudic 
nerve, or by intrinsic changes in the nerves incident to 
the leukemic blood. Of how much importance mechan- 
ical pressure by enlarged glands along the course of the 
nerves, or by pressure upon the veins, may be as a con- 
tributing cause in this condition, is not known at the 
present time. It is hoped that ere long a careful 
autopsic finding will clear up these theories, which 
seem at present to be mere surmises. 



FATAL HEMATEMESIS, THE KESULT OF CHRONIC 
GASTRIC ULCER. 

BY 

FRANK HALL MURDOCH, M.D., 
of Pittsburg, Pa. 

On September 20, 1899, Mr. L., aged 40, came to me 
complaining that for two or three months past he had 
experienced distress in the stomach, which came on two 
or three hours after meals, and which was relieved by 
eating. The night before I saw him he had such a 
severe attack of pain as to require the application of hot 
fomentations to his abdomen ; but he was not entirely 
relieved until he vomited. Examination showed the 
whole epigastric region very sensitive to pressure, and 
there was a circumscribed spot of tenderness to the left 
of the tenth dorsal vertebra. Suspecting an ulcer, he 
was put upon liquid food and bismuth. I also gave him 
some .5 gm. (8 gr.) orthoform powders with directions 
to take one should the pain return. That night and the 
next afternoon he again had an attack of severe pain, 
which in both instances was promptly relieved in 20 
minutes by this remedy. The diagnosis now being 
established the orthoform was discontinued. 

On September 25, the general tenderness over the 
stomach had disappeared, but a small circumscribed 
spot situated 2 inches below the xiphoid cartilage and 
extremely painful on slight pressure could easily be 
defined. This patient lived on liquids for 2 months, 
when, the tenderness on pressure having disappeared, 
he was permitted to take solid food and made an unin- 
terrupted recovery.' 

The subsequent history of the case is as follows : 

The patient enjoyed good health for four years after 
he first came under my care, but in January, 1903, he 
began to complain of attacks of bloating and belching, 
with pain coming on two or three hours after meals, 
which was relieved by taking sodium bicarbonate. 
These attacks came on every two or three months, and 
lasted a month or six weeks. For some years, and espe- 
cially during the past winter, he had used alcoholic 
liquors to excess, and when under their influence had 
been in the habit of eating most indigestible articles of 



January 6, 1906T 
Vol. XI, No. 1 J 



EUPTURED ECrOPIC PREGNANCY 



[American Medicine, 29 



food. However, during March, April, and May of this 
year he was unusually well, and experienced no trouble 
from his stomach whatever. About June 1, he began hav- 
ing pain immediately after partaking of either solid or 
liquid food, but instead of its being in the epigastrium, 
it was referred to the left hypochondriac region, and was 




took place can be distinctly seen in the accompanying 
cut. 

This is one of 32 cases'' of chronic gastric ulcer pre- 
viously reported, and the only one, so far as I have been 
able to ascertain, in which hematemesis occurred after 
the beginning of treatment. The patient had 
excellent health for four j'ears after first con- 
sulting me, and I firmly believe that had he 
lived a rational life, he would still be alive and 
well. 

1 would ask, had this patient consented to 
an operation, what surgical procedure would 
have succeeded iu arresting the hemorrhages ? 

REFERBNCKS. 

lOrthoform in the Diagnosis of Gastric Ulcer, 
New York Medical Journal, November 29, 1902. 

2 The Treatment of Chronic Round Ulcer of the 
Stomach, American Medicine, September 19, 1903. 



1, pylorus ; 2, cardia ; 3, pancreas ; 4, spleen ; 5, ulcer ; 6, open artery, 



not relieved either by the administration of sodium 
I bicarbonate or orthoform. Hot applications, or a large 
[enema of warm water, often gave relief. On June 20, 
'after taking some lamb broth, he was immediately seized 
; with severe pain in the epigastrium and left hypochon- 
driac region, which produced a condition of collapse, as 
his extremities grew cold, his skin became covered with 
a cold sweat, and he had great difficulty in breathing. 
Dr. F. D. Young, of Cambridge Springs, Pa., was called, 
and gave him a hypodermic injection of morphln, which 
relieved him, but Dr. G. E. Humphrey, also of Cam- 
bridge Springs, Pa., who had charge of the case, found 
it necessary to use morphin almost every day afterward 
on account of the pain and vomiting, until the morning 
of July 10, when he had a severe hemorrhage from the 
stomach, and soon afterward I saw him, in consultation 
witii the physicians mentioned. After the hemorrhage, 
he was fed by the bowel for some days, and had no pain 
or vomiting for a week. At the end of that time he 
wa.s able to take liquid food, which did not appear to 
give him pain, but vomiting soon returned and con- 
tinued at intervals until August 9, when he had several 
hemorrhages during the night. These were repeated on 
August 13 and 14, and every few days afterward until 
September 1, when he died. After the first hemorrhage, 
adrenalin chlorid 1 to 2,000 was administered in 20 drop 
doses, three times a day, by the mouth, and after the 
second hemorrhage, gelatin was tried. Operation was 
urged, but refused. 

The autop.sy showed a large chronic ulcer, which 
mea.sured 3Jx2J in., situated on the posterior wall of 
the stomach, and extending to, but not involving the 
pylorus, consequently th€'re was no dilation of the 
stomach. The base of the ulcer was formed by the pan- 
creas, to whi<!h the stomach was firmly adherent, and 
this no doubt accounted for the pain in the left hypo- 
chondriac region. The point from which the bleeding 



RUPTURED ECTOPIC PREGNANCY COMPLI- 
CATED WITH APPENDICITIS : OPERATION.' 

BY 

B. F. STEVENS, M.D., 
of El Paso, Tex. 

The comparative rarity of this condition is 
suflicient excuse for the report of the following 
case. Kelly, in his work on the "Vermiform 
Appendix and Its Diseases," reports only hav- 
ing seen seven cases in his clinic. Pozzi and 
Kelly, in their works on gynecology, only give 
it passing notice. 
The symptoms of an acute catarrhal appendicitis are 
familiar to all. The classic textbook symptoms of a 
ruptured tribal pregnancy are : Sudden onset ; extreme 
pelvic pain; rapid pulse without temperature; signs of 
shock more or less markegl, according to the amount of 
blood lost ; sudden anemia ; patient may or may not 
have been menstruating regularly, depending to some 
extent on the stage of gestation, though the menses 
usually cease as in normal pregnancy. 

Physical examination discloses tenderness and rigid- 
ity over either iliac fossa, with presence of a tumor 
of variable size on vaginal examination, or the whole 
abdomen may be filled with blood, depending on 
whether the rupture occurs in the free abdominal cavity 
or into the folds of the broad ligament, as occurred in 
my case. 

The symptoms of a right-sided ruptured tubal preg- 
nancy are very similar to those of an appendicitis. We 
may have an accompanying menorrhagia in any form of 
pelvic inflammation, probably most common, however, 
in affections of the tubes and ovaries. Increase of tem- 
perature does not occur in ruptured tubal pregnancy, 
unless infection follows, which it usually does sooner or 
later in unoperated cases. We may have exacerbations, 
or repeated hemorrhages in extrauterine pregnancy 
occurring every few hours or days, thus simulating an 
appendicitis. As before stated, in rupture into the folds 
of the broad ligament, the symptoms are milder, the 

' Read before El Paso County, Texas, Medical Society. 



30 A.JIKKICAN MEDICINBI 



EUPTURED ECTOPIC PREGNANCY 



C January 6, 190S 
Vol. XI, No. 1 



pain may be intense, but there is little shock and the 
patient recovers quickly. 

Early rupture is the rule. Pozzi reports 45 cases 
studied by Ilecker, 26 of which ruptured before or dur- 
ing the second month. In 141 cases studied by Von 
Schrenck, 13 ruptured during the first month, and 67 
during the second. My case was apparently three or 
four weeks along, the patient not having missed a single 
menstrual period. 

Case.— Mrs. M., aged 28. Family history negative. 

Personal //istory.— Negative. Patient has been mar- 
ried six years, and has one child, aged 4. She has 
had no miscarriages, menstruates regularly, and has 
always been well. 

Present Illness. — On December 15 she was suddenly 
seized with intense pain in the right lower quadrant of 
the abdomen, and also had a chill. She vomited pro- 
fusely, and showed signs of moderate shock. There was 
no increase of temperature. Pulse ranged from 130 to 
140. 

Physical Examination. — Patient was pale. There 
was marked tenderness and rigidity over the region of 
the right ovary. Vaginal examination disclosed a tumor 
the size of a hen's egg in the right side of the pelvis. 

Patient was given .02 mg. {\ gr.) morphin, and 
ordered to remain in the recumbent position with an ice- 
bag to the abdomen, no food or water to be given by the 
mouth. She was told that a ruptured extrauterine 
pregnancy was suspected, and that operation might be 
necessary. Early next morning I received a 'phone 
message that the patient was all right and that I need 
not call again, notwithstanding my explanation of the 
suspected gravity of her condition. Seven weeks later I 
was again called. I found the patient leaning over the 
edge of the bed, vomiting and crying, with intense pain 
in the right side. Physical examination at this time 
showed a tympanitic abdomen, with rigidity and ten- 
derness over McBurney's point. Vaginal examination 
showed the same tumor as before, the size of a hen's 
egg. The pain was so intense, and the patient so rest- 
less, that vaginal examination was unsatisfactory. Tem- 
perature was 102° P.; pulse, 120 ; leukocyte count, 15,000. 

A diagnosis of appendicitis was made and operation 
advised, which the patient refused. She was kept quiet, 
ice-bag to abdomen, no food or water by mouth for three 
days, and morphin as necessary for the pain. She was then 
put on liquid diet, and at the end of a week was sitting up. 
Ten days later she had a similar attack, which was 
treated as before, with apparent recovery. A week 
later she had still a third attack, each one apparently 
being caused by the ingestion of solid food. The patient 
now agreed to operation, which was performed six days 
after the inception of the last attack, and while she was 
still on a liquid diet. 

Operation. — Under ether anesthesia, after the usual 
preparation. The abdomen was entered through a 
median incision, reaching from the pubis nearly to the 
umbilicus ; patient in Trendelenburg position with in- 
testines packed off, disclosed a hematoma in the right 
broad ligament the size of a lemon. There were 
numerous adhesions between it and the omentum, in- 
testines, and appendix. The sac was very friable and 
was ruptured in taking it out. The appendix, which 
was red and edematous and quite adherent, was next 
removed, the stump being buried with a pursestring 
suture. The abdomen was closed in the usual manner. 
A washed-out iodoform gauze drain was left in Douglas' 
culdesac. Patient was given 800 cc. of normal salt solu- 
tion under the breasts before her removal from the 
table. She stood the operation well, there was almost 
no shock. The case ran practically a normal course to 
convalescence, with the exception of a stitch-hole abscess, 
which did not cause much trouble. 



The hematoma was the size of a small lemon. It 
contained blood clots, remains of portions of the ovary, 
and disintegrated fetus three or four weeks along. The 
walls of the sac wer^ extremely friable. This was 
apparently a ruptured ovarian tubal pregnancy, at the 
time of her first attack, rupturing into the folds of the 
broad ligament, which accounted for the small size of 
the tumor, quick recovery, and slight amount of shock, 
the pressure of broad ligaments tending to limit the 
amount of hemorrhage. 

The appendix was thickened, red, and edematous, 
and gave macroscopic signs of recent inflammations. It 
was 8cm. long by 2.5 cm. in circumference. In slitting 
open its lumen, a complete cicatricial stenosis was 
encountered at about its middle. The distal portion 
was distended with a muco-pus. There were no concre- 
tions or fecal matter in it. 

The patient left the hospital at the end of three weeks, 
and has had no further trouble since. 

The question arises, whether this patient's later 
attacks were due to the appendicitis or to exacerbations 
of the ovarian pregnancy. A menorrhagia followed in 
from 12 to 24 hours after the inception of each attack. 
She had a temperature ranging from 100° to 103° with 
each attack, except the first one, with a pulse of 120. 
She had no increase of temperature during her first ill- 
ness, but her pulse was rapid, from 130 to 140. The pain 
and nausea came on suddenly and were severe. The in- 
gestion of solid food seemed to be the cause of the last 
two attacks. I made only one white blood count, which 
was at the beginning of the second attack. This showed a 
moderate leukocytosis of 15,000, which of itself meant 
nothing. The contents of the hematoma showed no 
signs of infection. 

In my opinion, the first attack" was due to a ruptured 
ovarian tubal pregnancy, rupturing into the folds of the 
broad ligament. This was probably ovarian, because of 
the small amount of ovarian tissue remaining. The later 
attacks were due, no doubt, to the appendicitis. 

My thanks are due Dr. Hugh Grouse for suggestions 
regarding the management of this case. 



Tropic Cliiuatolog-y.^R. W. Felkin states that the 
normal temperature of Europeans in the tropics is about 
half a degree higher than in Europe. I'resh arrivals 
have a higher temperature than older residents, as the 
former do not perspire so freely. The daily range is 
rather less than in Europe. Exercise increases tempera- 
ture more quickly and it remains elevated for a longer 
time. Respiration is less frequent, oxygen inspiration 
and carbon elimination are diminished and the lungs give 
off less watery vapor. The pulse-rate is slightly slower 
and the heart does not beat so strongly. The urine is 
much diminished. There is a certain amount of anemia 
apart from pathologic processes. The nervous system is 
more or less enfeebled. The European's mental powers, 
after being stimulated for a few months, are depressed. 
Insomnia during the very hot weather prevents proper 
rest for the nervous system. Digestion is slow and 
imperfect. The liver secretions are often abnormal. 
Appetite is capricious. Weight is lost, muscular strength 
is lessened owing to want of tone. Repair after accidents 
is slow and nutrition is sluggish. Puberty comes a year 
or two earlier and miscarriages occur more frequently 
than at home. The simple fevers of the tropics are one 
of the myriad forms of heat or light fever. The light 
also produces nervous instability and irritability. The 
outer clothing should be white, gray, or yellow ; the 
underclothing black or yellow, [h.m.] — {^Archives of the 
Bontgen Ray, October, 1905.] 



JaM'Ary 8, 19C6"1 
Vol. XI, No. 1 J 



CORRELATION OF MEDICAL TEACHING 



[American Medicine 31 



SPECIAL ARTICLES 



CORRELATION OF MEDICAL TEACHING.' 

BY 

F. p. WESBROOK, M.D., 

of Minneapolis, Minn. 

Professor of Pathology and Bacteriology, University of Minnesota; 

and Director of the Laboratories of the Minnesota State 

Board of Health. 

At the present day the knowledge required of the 
practitioner of medicine involves so many phases of 
scientific advancement and human activity that to give 
the student a proper working equipment of principles 
sufficiently reinforced by practical illustrations, taxes to 
the utmost the resources of the school and the ingenuity 
and power of the teacher. The old-time physician was, 
In his day, the ideal preceptor or teacher of medicine, 
Jis the naturalist has been replaced by a group of special- 
ized workers in the biologic sciences, so the family 
doctor has been succeeded by a variety of specialists. 
Their knowledge in their specific lines is exhaustive, but 
each seems likely to have his general view somewhat 
curtailed and his perception of the importance and exact 
l)osition of his brother specialist's field partially ob- 
scured. 

The present highly artificial mode of life renders it 
necessary for the physician to keep paoe with develop- 
ment in commercial and economic activities, if for no 
other reason than that he may recognize and treat the 
diseases which result from specialized occupation, and 
may foresee and prevent opportunities for the transmis- 
sion of disease, which the complexities of modern rapid 
transit and the massing together of large bodies of 
people afford. 

The universal use of the microscope, with bacterio- 
logic and cultural methods, the very great advance in 
chemistry and physics in their application to the diag- 
nosis, prophylaxis, and treatment of disease, the study 
of animal parasites as infective agents and the interest- 
ing researches into the specific reactions of body fluids 
and tissue extracts leading to greater accuracy in the 
diagnosis and treatment of disease and the solution of 
certain medicolegal problems, render it necessary to 
train the student of today in a great many different 
lines. This cannot be done by a single teacher, but re- 
quires a large staff, and involves some dangers, espe- 
cially diffuseness. The old-time physician, acting as 
preceptor, if acute in observation and systematic in 
habits of study and record, was better able to correlate 
methods and results of observation and treatment for 
his pupil. 

The medical school was founded with the hospital as 
the center from which instruction radiated and very 
rightly the patient continued to be the special object of 
study. As students increased in number, it became 
necessary to establish different chairs of instruction, and 
faculties were subdivided into the primary and clinical 
branches. The lecture method of imparting information 
prevailed and we all remember with pride and affection 

' Read before the Minnesota State Medical Society, St. 
Paul, June 1, 1905. 



certain of our teachers whose eloquence has left its per- 
manent impress upon us even if the truths, at that time 
so clear, have faded from memory. We all likewise 
recall that each branch <)f instruction constituted a study 
entirely by itself and relationships of studies were abso- 
lutely undefined unless the instructor went outside the 
bounds of his own subject to point out relationships and 
the application of the truths he taught. While such 
duplication is bad, the failure to define boundaries was 
even worse, since it often left deserts in our education 
which years of the study and practice of medicine fail 
to render fertile. 

In order to keep pace with the advance of modern 
science and to help students to retain knowledge of 
specialized methods and their application by affording 
opportunity to put them into actual practice, the prac- 
tical laboratory method of instruction has been adopted 
for the primary branches. The cost of the laboratories 
has become so great that it seems likely that the com- 
mercial medical school, dependent upon student fees, 
must give place to the university with private endow- 
ment or State support, because in addition to the ex- 
pense of building and equipment, laboratories require 
large corps of thoroughly trained men whose time shall 
be given altogether to the work of teaching and research. 
These men can be paid in part by opportunity for re- 
search, but must also receive sufficient income to live 
like their clinical brethren and maintain their profes- 
sional status. There is a tendency to develop special 
laboratories purely for research, but to divorce teaching 
from research will prove disastrous since an atmosphere 
of research is absolutely essential for satisfactory teach- 
ing. 

Close relationship to hospitals enables the laboratory 
man to take his proper place with the clinician in the 
study of disease, but it seems probable that the present 
tendency for the laboratory man to confine himself to 
teaching and research will increase. If such speciali- 
zation is desirable, it can only be obtained by providing 
proper compensation for the laboratory man, otherwise 
he will be forced ultimately into practice. 

In the endeavor to systematize for the student the 
knowledge which the laboratory study and methods 
afford, and to preserve certain times of the year to the 
instructors for research, the socalled "concentration" 
method of study has been adopted in some of the uni- 
versities, with the case method of instruction in the 
clinical branches. Harvard has been the chief exponent 
of this system and Minnesota has followed. After an 
experience of several years it seems well to consider the 
possibility of improvement upon the method. 

In the " concentration " method used in Minnesota 
the year is divided into two semesters and each semester 
into two equal parts. During the first year the whole of 
the first semester is equally divided between anatomy on 
the one hand and histology and embryology on the 
other, and the second semester is divided between phys- 
iology and chemistry. In the second year the first 
semester is divided between therapeutics, physiology, 
and chemistry, and the first half of the second semester 
is given to anatomy and histology and embryology, the 
second half of the semester being devoted to general 



32 



American Mkdicine] 



COEEELATION OF MEDICAL TEACHING 



CJanvaky 6, 1906 
Vol. XI, No. 1 



bacteriology and pathology. The method of operation 
may be illustrated by stating that the student in the first 
semester of his Freshman year spends a half of each day 
in the anatomic laboratory and the other half in the 
laboratory of histology and embryology. The same 
arrangement obtains in the second semester for chemistry 
and physiology. Formal lectures are largely replaced by 
laboratory talks based upon the student's practical work 
and given as the need arises. When a thorough knowl- 
edge of anatomy, histology, embryology, physiology, 
and chemistry has been acquired the students devote 
every day for the last two months of the second year to 
study in one laboratory, where they are taught the 
subjects of general pathology and bacteriology. Instruc- 
tion in bacteriology deals with the preparation of 
mediums, the biology and physiology of bacteria, and 
the various technical methods which are employed in 
the identification of the bacteria and their isolation in 
pure culture, bacteriologic examination of water, the 
action of physical and chemic agents upon bacteria, and 
in general, those phases of bacteriology which must be 
known before specific study of disease can be undertaken. 
When familiar with the general principles of bacteriology, 
general pathology is begun. This includes instruction 
on inflammation, degenerations, immunity, fever, anti- 
toxin, and serum work and the genera! })rinciples of 
tumors, etc. The two subjects are thus interwoven and 
the underlying principles of hygiene inculcated. In the 
first half of the third year, the entire time of four after- 
noons per week is devoted to what is known as special 
pathology and bacteriology. The pathology of the various 
diseases is taught and studied in special relationship to 
etiology. For instance, in tuberculosis, bacteriology is 
first taken up, and several varieties of tubercle bacilli 
studied and grown on the various mediums. Technical 
methods already learned are used by the students for the 
demonstration of the tubercle bacillus in tissues, fluids or 
other materials where it is commonly found. The 
whole life history of the organism is followed out, and 
its resistance to harmful agents is studied so that the 
principles and methods of protecting the public against 
this disease may be well understood. Ani;nal inocula- 
tion is practised in order to study the pathology of 
tuberculosis. Thus the general and special effects due 
to difference in the portals of infection, the size of the 
dose, the virulence of the organism and the resistance of 
the host are all considered. The students learn not only 
the history of the typic tubercle and the details of its 
constituent elements, but other factors in regard to paths 
and methods of extension of the process with caseation, 
calcification, etc. Each tissue of the body is studied in 
gross and microscopic specimens from man and animals, 
and all available autopsy material is utilized. The other 
infective granulomas are studied in the same way at this 
time. Similar methods are used in the teaching and 
study of typhoid fever, the septic processes including 
pneumonia and anthrax, and throughout the work the 
pathology and hygiene of the various diseases are 
studied in relation to their bacterial cause or hematology 
and biology, in the ca.se of animal parasites. This 
leaves, of course, quite a number of diseases and patho- 
logic processes still to deal with. The method of corre- 



lating bacteriology and pathology in this way has 
yielded such satisfactory results that it seems wise ot 
extend it in order that thechairs of medicine and surgery 
may arrange their work, so as to take up the various dis- 
easesjust when the students are studying or have finished 
their laboratory work in bacteriology, pathology, hema- 
tology and parasitology. In fact, if such correlation 
could be extended throughout the medical course, so as 
to include all years, it would be most advantageous. In 
any event, approximation to this ideal is to be desired 
and sought. 

When students come to a medical college fully 
equipped in the humanities, including modern lan- 
guages, and with mathematic, physic, chemic and 
biologic training sufficient for their needs, some such 
course as the following might be pursued. 

1. The time could be divided for the first few weeks 
among the laboratory subjects in order that the neces- 
sary general principles and technical methods might be 
instilled. For the sake of both teachers and students, 
these might be grouped in pairs so that the mornings 
could be given to one subject and the afternoons to an- 
other. 

2. When such general knowledge and technic have 
been acquired in the branches of anatomy, histol- 
ogy, embryology, physiology, physiologic chemistry, 
etc., instruction should be given in the various branches 
along the lines of organology and special tissue study. 
For instance, when the anatomist has inculcated the 
musculature of the body with information in regard to 
the site, origin, insertion and relation of the various 
muscles, the histologist could take up the minute struc- 
ture and the physiologist teach function with the neces- 
sary theory and experimental work within his province. 
The same method could be followed for the vascular and 
nervous systems and such related instruction is cer- 
tainly to be desired particularly in dealing with the 
various organs of the body. The student should receive 
all his information and see each organ from the various 
points of view before having his attention distracted by 
other lines of instruction. At best he is apt to be some- 
what mixed in his ideas and his sum total of informa- 
tion is not so readily available when the minute anatomy 
of an organ is taught him a long time after he has gone 
over his gross anatomy or geography. Function, too, 
cannot be understood without a knowledge of gross and 
microscopic structure and all three should therefore be 
taken up at approximately the same time. This principle 
of instruction along the lines of organology seems to be 
the most important in the first two years of medical 
training. 

3. When such accurate and correlated knowledge of 
the normal has been acquired, the general principles and 
necessary technic of general pathology and bacteriology 
should be given, and might very well alternate with 
similar instruction along the lines of physical diagnosis 
and pharmacology in the latter portion of the second 
year. 

4. In the last two years of a four-year course, when 
fully equipped with general principles and technical 
methods, both third and fourth year students might well 
take up the work together, since the full two years 



January 6, 1906T 
Vol. XI, No. 1 J 



CORRELATION OF MEDICAL TEACHING 



(American Medicinb 33 



would probably be necessary in order to cover all of the 
; more common diseases. A single group of diseases or infec- 
tion should be taken up at a time from the standpoint of 
K etiology. When of bacterial origin, the bacteriology of 
'. the disease should be thoroughly inculcated, and the 
practical e.Kperimental work of the student supple- 
mented by demonstrations. When infection depends 
upon hematozoa or other animal parasites, the same 
method can be employed. The pathology of these dis- 
eases and a thorough study of all of the tissues and organs 
of the body should be made at this time, so that the 
relationship of the local lesions, both gross and micro- 
scopic, to the general infection or disease process may be 
defined and understood. 

Now is the time also to take up the special methods 
of protecting others from infection, when the nature and 
resistance of the virus, portals and paths of infection, 
means of elimination and such other basic details are 
under consideration. Hygiene thus taught is practical. 
The students are now prepared to receive instruction 
from the profes.sor of medicine and his associates, and to 
study cases of tuberculosis in the hospital and dis- 
pen.sary. The professor of surgery, the orthopedist and 
gynecologist should take up the diagnosis and treatment 
of tuberculosis as it falls within their province. By 
such united effort, the student would have a compre- 
hensive knowledge of tuberculosis, which it is impos- 
sible to acquire by the present disconnected methods in 
the same length of time. Nor should his knowledge of 
detail be less exhaustive becau.se his grasp of the general 
problem is firm. In this way, if the more common dis- 
eases are studied and the student receives full informa- 
tion as to cause, general and local processes, preven- 
tion, diagnosis and treatment of a single disease at one 
time, it will be possible for him properly to appreciate 
relative values. The experience of all of us has been 
similar. We have received instruction on human anat- 
omy. We may or may not have learned the use of the 
microscope and the minute structure of cells, tissues and 
organs. We may have had some lectures in physiology, 
and we may or may not have had experimental work, 
including physiologic chemistry and pharmacology. In 
any event, our information concerning the various 
organs or tissues has been received at irregular intervals 
from various instructors, and the amount of information 
retained and the vividness of our impressions have de- 
pended largely on the character, individuality and force 
of the instructor. Relationship of structure, develop- 

Ient, and function, have never been made clear. 
This is equally true in the later years of our student 
lys, when the cause of disease and the local and gen- 
al changes in anatomy and function have never been 
operly adjusted in our minds to the physical signs, 
o^mptoms, and treatment. It was quite common, and 
K still common, to teach the pathology of the individual 
latomic systems, with the result that tuberculosis, 
phills, typhoid fever, or some other general disease 
hich produces far-reaching results in many organs 
xuay be considered a number of times without affording 
a proper conception to the student of the whole process. 
For instance, the pathologist may teach tTlberculosis of 
the lungs and a few weeks later tuberculosis of the 



spleen, liver, intestine, or brain. At some other time, 
the professor of medicine, in taking up diseases of the 
chest, deals with tuberculosis, and the professor of sur- 
gery may not give instruction even in the same year on 
surgical tuberculosis. Here, too, the impression which 
remains with the student must again vary with the in- 
dividuality and force of the teacher and with the oppor- 
tunities at hand for illustration. Without correlation 
and the general summing up of these processes, it is 
very possible for one branch of medical teaching to be- 
come exploited and advanced at the expense of another 
equally important branch. Under present arrange- 
ments, medical teaching is likely to continue to be most 
irregular, and the student will be unable at any time — 
unless he has developed system more than most medical 
students are accustomed to do — to summarize his knowl- 
edge concerning any particular disease or disease process 
in relation to diagnosis, prevention, and treatment of 
that particular condition. 

The " case method " of instruction is most important 
and should be included in such a general scheme as has 
been outlined, so that in the final two years the patient 
is the center of teaching and study. No individual 
case, however, is able to afford complete instruction on 
all the phases of medicine, and it will become necessary, 
therefore, to systematize certain wards or parts of the 
hospitals for this plan of teaching and research. 

The main difficulties which such a plan suggests are 
the facts that one particular department may have a tre- 
mendous amount of work thrust upon it for a given 
period of time and for some time thereafter have little to 
do, while other phases of the particular subject are being 
presented by other teachers. Such time can be utilized 
in preparation for the next installment of work. Diffi- 
culties, too, in securing clinical material for illustration 
and study may be encountered, but these can be met by 
proper systematization. In Cambridge, Eng., there is a 
plan under consideration of which, as yet, no details 
have been published. This has for its object the for- 
warding of specially selected cases to Cambridge by 
skilled observers throughout the whole of Britain who 
are in sympathy with the project and are members of 
this Medical Research Society. A complete bibliography 
is compiled, including all phases of the particular disease 
which it is desired to study at that time. This bib- 
liography is at the disposal of each member of the 
society, and through a central office each one of the mem- 
bers throughout the country is to be kept in constant 
touch with the work and is to furnish suitable ca.ses to 
this central hospital as opportunity arises. The hospital 
is in direct relationship with the Cambridge laboratories, 
where concurrent chemic, bacteriologic, and pathologic 
studies of blood and various secretions, excretions, tis- 
sues, cells, and body fluids may be carried on. 

A somewhat similar plan of cooperation with the 
alumni of any university would permit of the study of 
cases in series and could be utilized for undergraduate 
teaching. The study of typhoid fever or, pneumonia 
offers no difficulties, since instruction in these diseases 
could be arranged for at the time of year when they may 
naturally be expected. This is true also of scarlet fever 
and diphtheria. The pus infections and tuberculosis 



34 A.MERICAN Medicine] 



DIGEST OF MEDICAL LITERATURE 



CJANDARY 6, 1906 
VOL. XI, No. 1 



may be studied at any time, since it is always possible to 
secure material and the rarer infectious diseases could be 
studied by keeping in touch with enthusiastic alumni 
or studious medical men in the neighborhood of the 
medical school. Even small hospitals could be made to 
serve the purpose if due selection of cases was exercised 
and the central ofHce were sufficiently well organized to 
keep in constant touch with energetic practitioners who 
might reasonably expect to be furnished with a complete 
record of the clinical histories, laboratory findings, 
course of treatment, and results obtained. While it 
must be admitted that it would be impossible to study 
all of the diseases in relationship to their etiology, it 
should be done so far as possible and the fullest correla- 
tion between the various instructors should be main- 
tained, so that full and complete information concerning 
the selected disease or process may be received from all 
of the sources at approximately the same time, in order 
that the total accumulated information may be filed at 
once, both in the mental compartment and written record. 

It is probable that the teaching of today is too diver- 
sified and that attempt is made to cover too much 
ground. At best, the student can only be taught certain 
general principles and how to observe. It is, therefore, 
best to illustrate the methods of observation by the 
thorough study of a few disease processes rather than to 
attempt to cover the whole field of medicine. If he be 
properly taught how to approach his cases in a system- 
atic way and to utilize every method of observation, the 
student's only difficulty will be to weigh the evidence 
which his eyes, ears, hands, microscope, or chemic tests 
afford him. If he is able to diagnose accurately the 
commoner disease processes and the changes which have 
been produced in the various tissues and organs of the 
body, if he knows the general principles of therapy and 
is taught to advise his patient and to protect others with 
whom he may be brought in contact, he can easily adapt 
the same methods to the study of other processes and 
other diseases when the necessity for it arises. Such a 
general plan of teaching will eliminate the dangers of 
too great specialization, whether along laboratory or 
clinical lines, and will promote the use of logical 
methods of deduction and neutralize the present ten- 
dency to "cocksureness," with the possible oversight of 
important associated or causative conditions. 

Where so much is at stake, no effort should be 
spared, and we should not close our eyes to the present 
difficulties and dangers. At best, the machine must be 
complicated, but it may be made to work with smooth- 
ness and regularity if molded upon the lines of modern 
business enterprise. In any event, the public has a 
right to expect that medicine, the most important of all 
the professions, be taught as carefully and systematically 
as engineering or other technical work. 



No Vaccination; Scliool Shut. — A peculiar di- 
lemma exists in the Stouffer school, in Bullskin town- 
ship, near Connellsville, Pa., owing to a vaccination 
order. A few days ago State Commissioner of Health 
Dixon ordered all pupils that had not been vaccinated to 
go home, and when the order was obeyed not one of the 
38 pupils remained. The residents are opposed to vac- 
cination and the feeling is bitter. 



DIGEST OF MEDICAL LITERATURE 



TROPICAL MEDICIJfE. 

MALTA FEVER. 
A CRITICAL REVIEW OF RECENT INVESTIGATIONS. 

BY 

MAJOR CHARLES E. WOODRUFF, 
Surgeon United States Army. 

Malta fever, not being a disease of this country, has 
not received attention from American physicians, 
except as a matter of general or scientific information, 
but the increasing number of cases imported into the 
United States, and treated as rheumatism or malaria, 
makes its study of practical importance now that so 
many Americans visit countries where they may con- 
tract the disease. Recent investigations have also shown 
the possibility of the importation of the causative 
bacillus in other ways than in an infected human host. 
A review of its history and of the recent discoveries in 
its etiology is therefore of timely importance as it is not 
at all unlikely that cases might also arise here in the 
future. The disease has long been known by the British 
profession and dreaded by the army and navy stationed 
in the Mediterranean basin. On account of the large 
numbers of officers and sailors disabled now and then, it 
has caused considerable alarm. Its mortality was not 
large — about 1'fo — but its course extended over such a 
long period as to create a very disabling amount of 
invalidism. It averages three months in duration, 
though it may extend over a period of two years in 
exceptional cases. 

It bade fair to jeopardize the British control of the 
Mediterranean, and it became a military necessity to learn 
how it was contracted and how it could be avoided. The 
British Colonial Secretary, therefore, in 1904 suggested 
to the Royal Society that a thorough investigation of 
the disease be undertaken. A joint commission of med- 
ical officers of the army, navy, and civil government of 
Malta was thereupon organized under the advisory 
supervision of the Royal Society, and their latest or 
third report proves to be of extreme value, not only from 
the practical side, but also from the scientific interest it 
is bound to arouse. 

For a long while the disease was not recognized as 
a separate infection having its own specific cause. To 
be sure it was named from the locality — Malta fever, 
Mediterranean fever, Gibraltar or Rock fever, Neapolitan 
fever — but the other names given to it rather indicated a 
tendency to look upon it as an aberrent form of some 
other infection — relapsing typhoid, intermittent, rheu- 
matism, undulant fever, sweating sickness, and such 
names were quite common. Its undulating course 
naturally led to the opinion that it was either malaria 
or typhoid with relapses, or a combination of both, but 
the discoveries of Laveran and Widal eliminated these 
infections from the problem. 

The general picture of an infection, the soft, enlarged 
spleen, and occasionally enlarged liver, but no other 
lesions, the constipation, anemia, and debility, the period 



JANUARY 6, 1906T 
VOL. XI, No. 1 J 



DIGEST OF MEDICAL LITERATURE 



fAMERICAN MEDICINK 35 



of incubation of 6 to 10 or even 20 days, and the numer- 
ous pyretic periods of 1 to 3 weeks, with apyretic inter- 
vals of 2 or more days between, soon led investigators 
into a search for a bacterium. Such an organism would 
explain the malignant types fatal within 10 days, the 
intermittent types so closely resembling malaria, the 
neuralgic or arthritic complications with effusion, the 
invasion of the fibrous structures, and the occasional 
involvement of the testicles. 

Through the efforts of David Bruce, of the Royal 
Army Medical Corps, Micrococcus melitensis was 
finally isolated in 1887 from the spleen of fatal cases and 
proved to be the cause. Agglutination tests were 
quickly devised, so that it was possible to make a defi- 
nite diagnosis as early as the sixth day of the fever. It 
was now known for certain that the many fatal cases 
which showed the postmortem lesions of typhoid were 
not Malta fever at all but true typhoid. In true Mediter- 
ranean fever the morbid postmortem findings are merely 
those due to a prolonged toxemia, such as granular and 
fatty degenerations. 

For eighteen years no further advances were made. 
The manner in which the bacillus entered the body was 
wholly unknown, opinions being naturally divided as 
to whether it was by air or water, though, curiously 
enough, there do not seem to have been serious discus- 
sions as to whether it could be introduced by foods. 
This omission from the accounts of the studies of the 
disease is most remarkable in view of the last report of 
the commission, which now leads investigation in that 
direction. 

There did not seem to be any particular environment 
or set of conditions which could be held accountable. 
Cases would even arise spontaneously in hospital under 
sanitary conditions considered ideal. Sailors on ships, 
soldiers in garrison, and civilians on shore were stricken 
indiscriminately and without apparent reason. 

The commission naturally directed attention to the 
viability of the micrococcus, and it was found to be most 
resistant. It survived 20 days in dry sand and as long 
as 72 days in damp soil, and a month or so in fresh or 
sea-water. The first report of the commission was pub- 
lished in the spring of 1905, and seemed to indicate that 
dust inhalation might be responsible, and certain experi- 
ments seemed to point that way. Two independent 
workers, Ross and Levick,' reported that they had ex- 
perimented upon themselves by inhaling infected dust 
and did not contract the disease. At the suggestion of 
Ronald Ross, they also unsuccessfully made numerous 
experiments with stegomyia mosquitos. They also 
proved that it was not transmitted by fomites or by 
direct contact with patients, though it can be contracted 
by laboratory workers, probably by accidental inocula- 
tion. Nor were they able to infect themselves by swal- 
lowing infected water. 

The source of the infection was thus as much a 
mystery as ever. The second report did not help mat- 
ters in this regard, though it contained much valuable 
information, especially as to the very long time 
the micrococcus could survive in various mediums 

' British Medical Journal, April 1, 1905. 



outside the body. It also was shown that the virulence 
of the organism was greatly exalted by rapid passages 
through guineapigs. 

The third report mentions the fact that the organism 
can be obtained from the blood of about two-thirds of 
the patients, though not in large numbers. The higher 
the fever and the lower the agglutinating power of the 
blood, the fewer were the organisms recovered. They 
were found at all stages of the disease, and were more 
■ apt to be present in the late afternoon than in the fore- 
noon. They were never recovered from the skin, 
sputum, breath, or the perspiration, but the urine con- 
tained them as a rule, sometimes in large numbers for 
a short time, but usually in small numbers as long as 
there was any fever. In one case they were recovered 
from the urine on the two hundred and forty-ninth 
day of the disease. 

There were also further reports as to the long period 
of survival of the organism on various mediums, both 
dry and moist. 

The most important discoveries were in relation to 
goats. It was found that over half of the animals exam- 
ined gave a positive reaction to agglutination tests, and 
that one or more apparently healthy animals in every 
herd were excreting the micrococcus in their milk and 
urine. Goats which gave a negative agglutination test 
were fed with the living organisms, and within a few 
weeks gave a positive reaction and, in course of time, 
the organisms appeared in the urine and milk in 
enormous numbers. In one case the milk was still 
crowded with them nine months after the feeding. 
Moreover, the milk might contain considerable num- 
bers and yet present no chemic or physical changes to 
arouse suspicion. 

Though some experiments in administering infected 
food or water have failed, others have succeeded, and it 
is a fair inference that, as goats are proved to be infected 
in this way, it is the manner of human infection also. 
It is, therefore, generally believed that the commission 
has finally struck the right trail, and that practical 
prophylactic means will promptly follow. 

It is now quite evident how men could have been 
infected by foods, though living in surroundings appar- 
ently ideal. It also explains why cases could originate 
in hospital, and also why it is so often a disease of the 
young, most of the cases being from 6 to 30 years of age. 
It reminds one quite forcibly of a similar revelation, fol- 
lowing the discovery of the transmission of yellow fever 
by mosquitos, as to whj' patients could be infected 
though living in a sanitary manner. The mosquito was 
overlooked, and in the case of Malta fever, fresh milk 
from apparently healthy goats might be swarming with 
bacilli and its dangerous character unknown. To Amer- 
icans who have not visited the Mediterranean, and par- 
ticularly Malta, it must be explained that the goat fills 
a very important economic role on account of the impos- 
sibility of keeping cows. Some idea of these conditions 
must be obtained before one can appreciate the full sig- 
nificance of the new bacteriologic discoveries. It might 
be said that the whole Mediterranean basin has been the 
seat of numerous civilizations for many thousands of 
years. Populations have suffered great fluctuations in 



36 American Mbdicini^ 



DIGEST OP MEDICAL LITERATURE 



CJANUAEY 8, 1606 
Vol. XI, No. 1 



density and have at times been quite numerous. Forests 
have been cut down and lands placed under cultivation, 
but the soil has been washed away by rains, so that once 
productive places are now more or less barren. Inten- 
sive cultivation has resulted in increased population, so 
that in many places every available inch of ground is 
now under cultivation. 

In Malta and elsewhere the hills are all terraced to 
secure little flat areas for garden vegetables principally, 
the soil being held up by ma.sonry walls. A horizontal- 
view of parts of the island shows only the walls and 
gives a stranger the impression that the whole land is a 
rocky barren waste, but a ride into the country shows it 
to be a green garden spot. There is, of course, no grass 
for cattle, and as a matter of necessity goats are used, as 
they thrive on foods which would starve other rumi- 
nants. Indeed, a stranger often wonders how they exist 
at all. They apparently digest cellulose to a greater 
extent than is generally believed, and herein is their 
value. 

Through centuries of selection a breed of goats has 
been produced which gives large quantities of millf. 
The little herds of these are driven from door to door 
and milked as needed. The udders are almost as large 
as those of our common or range cattle and the animals 
strike the visitor as one of the curiosities of the place. 

If it proves to be true that this special breed of goats 
can harbor Micrococcus melitensis in such large num- 
bers, and yet show no evidence of disease, and if the 
milk can be swarming with the organisms and yet be 
apparently normal, it is quite evident that the investi- 
gators have stumbled upon another instance of "toler- 
ant immunity." In past ages the organism has, no 
doubt, been a .saprophyte which has taken upon itself a 
parasitic existence, but through many centuries of ad- 
justment by survival of the least virulent invaders and 
the most resistant hosts, the two live in apparent har- 
mony. This process has been most interestingly de- 
scribed as to other organisms by Professor Theobald 
Smith, of Harvard University, and other biologists also. 

Whether the invading organism confers any benefit 
to the host so as to be classed as a symbiotic remains to 
be proved. Nor is it known whether it normally still 
lives a saprophytic existence while traveling from host 
to host. Its vitality when dried and the ease with 
which it can be carried from goat to goat, being excreted 
in such numbers in the urine, would lead one to believe 
that it lives only in the goat or allied animals. 

Its normal home being in the goat, it finds a new en- 
vironment in other animals which may kill it promptly 
if they are racially immune, or which may let it live as 
in man if conditions are favorable. Malta fever is not, 
properly speaking then, a human disease at all in the 
sense of such diseases as the exanthems presumably due 
to pure parasites which do not invade other animals but 
man. It is more of the nature of glanders and anthrax 
— an accidental infection due to an organism properly 
belonging to some other animal. There is this differ- 
ence, however, the bacilli of glanders and anthrax have 
not yet established harmonious relations of tolerant im- 
munity or symbiosis, and are still at work killing off 
many of the animals they invade. 3Hm'ococcus melitensis 



on the other hand has had thousands of years to estab- 
lish its present relations, for the Mediterranean domesti- 
cated goat is no doubt a descendant of domesticated 
goats of prehistoric civilizations of this part of the 
world. 

The relation to man of the diseases of the domesti- 
cated and wild animals, the human diseases caused by 
symbiotic organisms of these animals, are becoming 
of greater importance every year. The matter was re- 
cently discu.ssed by Theobald Smith before the American 
Public Health Association.' He shows that bovine tu- 
berculosis may be mild and latent, though perhaps the 
bacilli may be discharged from the secretions. Though 
he does not believe in the identity of human and bovine 
tuberculosis, he clearly shows that the bovine form can 
be transmitted to human beings, most of the cases, 
though, being in children. In glanders, also, a disease 
closely allied to tuberculosis, there are many horses 
found to harbor the organism harmlessly, so that the 
process of an evolution of a tolerant immunity is now 
going on. It would not be at all unlikely that we will 
find that Malta fever is similarly an accidental infection 
by an organism belonging to the goat in which it has 
established a right to live. 

The practical importance of the matter lies in the fact 
that it has been proposed to import Maltese goats to this 
country for their milk. It is presumed that they are 
immune to tuberculosis, and that their milk will assist 
in establishing an immunity in children or adults to 
whom it is fed. If true, it would no doubt be a valuable 
addition to the other therapeutic measures for the tuber- 
culous. It has been pointed out, nevertheless, that in 
avoiding the Scylla of tuberculosis, we might be destroyed 
by the Charybdis of Malta fever. We cannot disturb the 
geographical distribution of animals too radically. Malta 
fever is, indeed, a problem of the tropics not at all dis- 
similar to our tuberculosis situation. Malta fever has 
been recently reported from Shanghai,^ the cases having 
been previously considered to be either enteric or mala- 
ria, and the diagnosis has been verified by Kitasato. It 
is also known in the islands of the Caribbean Sea and in 
South America. It is not at all unlikely that it is the 
real diagnosis in some of our obscure Southern fevers 
which are neither typhoid, paratyphoid, nor malaria. 
It exists in the Philippines. Indeed, it seems to be a 
tropic or subtropic affair the world over. The bacillus 
may be destroyed by northern climatic conditions on its 
way from host to host, in like manner to the death of 
the pneumococcus in the arctics. It may be unable to 
live in any other animals than the goat or possibly the 
sheep. The danger from it does not seem to be great in 
this country, but it is a danger, nevertheless, which it 
would be well to keep in mind. What animals harbor 
it in the West Indies, or possibly our South, cannot be 
surmised, but it is a matter for early investigation. 



The Paris Academy of Sciences has awarded the 
Lalande prize to Professor William Henry Pickering, of 
Harvard University. 

1 Boston Medical and Snrgical JonrnRl, November 2, 1905. 
'American Medicine, Vol. ix, p. oil, 1905. 



January 6, 1906T 
Vol.. XI, >o. 1 J 



DIGEST OF MEDICAL LITERATURE 



[American Medicine 37 



PATHOLOGY. 

THE RELATION OF SPIR0CH.S;TA PALLIDA TO 
SYPHILIS. 

A CRITICAL KEVIEW OF RECENT INVESTIGATIONS. 

BY 

ALLER G. ELLIS, M.D. 

During the few months which have elapsed since 
Schaudinn and Hoffmann announced their discovery of a 
spirochseta in the lesions of syphilis, numerous reports 
from other observers have appeared, the majority being in 

; German periodicals. In general, the findings of Schaudinn 
and Hoffmann have been confirmed and extended to 
include the presence of S. pallida in the local lesions of 
primary, secondary, and tertiary syphilis, in the blood of 

: syphilitics, and in the internal organs of infants dead of 
congenital syphilis. Some writers do not hesitate to assert 

■ their belief that S. pallida is the exciting cau.se of the 

; disease, but the majority are more conservative and are 
at present content to announce their findings without 
drawing positive conclusions. The appended brief 
abstracts of papers on this subject furnish a running 
summary of the work which has been done during the 
summer; from theije papers the complete bibliography 
can be traced. A large addition to the literature of the 
subject may soon be expected from American and Eng- 
lish investigators, many of whom are collecting ex- 
tended series of cases before publishing their results. 

Buschke and Fischer' recovered S. pallida from the 
liver and spleen of an infant dead of hereditary syphilis. 
The organism was not found in the juice from lymph- 
nodes nor in excised papules, but was found in l)lood 
removed from the subject during life. 

Levaditi ^ found in one case of hereditary syphilis a 
few spirochtetas in vesicle fluid and a great number in 
the scrapings from ulcers. In a second case the liver, 
spleen and lungs contained spirochsetas, most numerous 
in the liver. In a third case the spleen, liver and 
pemphigoid lesions contained the organism. The rich- 
ness of the liver in spirochfetas is regarded as pointing to 
infection through the placenta. 

Salmon,' in a case of hereditary syphilis, found 
numerous spiroehaitas in scrapings from pemphigus bul- 
las. No other organisms were found. Spirochajtas were 
not found in the blood or in the nasal mucosa. 

Moritz * found numerous spirochsetas in the bone 
marrow and muscularis of the small intestine of a sub- 
ject in which the pathologic diagnosis was grave anemia 
with degeneration of the bone marrow, gastric and intes- 
tinal ulcers, fibrinous pleuritis, and lobar pneumonia. 
He stained only with thionin ; that the organism was 
the pallida api)ears uncertain. 

Hoffmann '■• demonstrated S. pallida in pemphigus bul- 
las, inguinal lymph-nodes, liver, and spleen of a child 
dead 10 hours from syphilitic pemphigus. It was also 
present in typic form in closed papules remote from the 
genitals. 

Zabolotny " isolated *S'. pallida from the contents of 
enlarged lymph-nodes and excised papules of secondary 
syphilis. He believes the jmllida plays a role in syphilis, 
but we do not yet know if the spirochajtas themselves 



produce the lesions or if they represent only the transi- 
tion form of some other parasite. 

Fraenkel ' believes S. pallida is in etiologic relation 
to syphilis, and cannot understand why it was not earlier 
discovered. He finds the organism in almost every case 
of early syphilis. They are unevenly distributed, and 
extended search through a large number of fields may 
be necessary for positive diagnosis. 

Levaditi, Nobecourt and Darre ' found S. pallida in 
the cutaneous lesions of a congenital syphilitic but not 
in the viscera or bone marrow. 

Flexner and Noguchi' demonstrated S. pallida in 
three of our cases of syphilis and failed to find it in 
two nonsyphilitic ulcers of the penis. In one case no 
spirals were found in stained spreads, although they ap- 
peared in the fresh material. 

McWeeney'" found the organism in each of nine 
cases of syphilis ; he discusses the possible nature of the 
spirochseta. 

Tchlenoff" reports a study of 14 cases of syphilis, 
both chancres and inguinal lymph-nodes. He found 
S. pallida in all chancres and moist papules and also in 
one lesion of the tongue and one inguinal bubo. 

Hirxheimer and Hubner'^ found *S'. pallida in the 
primary and secondary lesions of 14 cases of syphilis, but 
did not find it in the blood. In the superficial portions 
of the lesions, S. refringens was often found. 

Raubitschek " found spirochajtas in the condylomas of 
a syphilitic and also in the blood taken from a finger. 

Kiolemenoglou and Cube" say that nonspecific 
lesions have not been searched for similar organisms 
thoroughly enough to make possible definite conclusions 
regarding S. pallida. They have found a spirochseta 
which could not be differentiated from the pallida in the 
secretion of an inflamed phimosis, in gonorrheal pus, 
simple balanitis, Bartholinian and scrofulodermic ab- 
scesses, necrotic carcinomas, and in pointed condylomas ; 
it was always accompanied by the refringens. 

Delamare and Tanasesco '^ found ^S*. pallida and B. 
fusiformis in a syphilitic chancre. This association pos- 
sibly explains the phagedenic character of the chancre. 
[In view of the frequent association of fusiform bacilli 
and other forms of spirillums, the finding of these ob- 
servers is of special interest. Very suggestive in this 
connection is the paper by Weaver and Tunnicliff,'" who 
grew mixed cultures of fusiform bacilli and spirillums 
from healthy mouths upon human pleuritic exudate and 
broth. Although the spirillums were never grown in 
pure culture, the possibility of obtaining even a mixed 
culture of the pallida when found with the fusiform 
bacillus should be borne in mind by those who are in- 
vestigating the former.— A. G.E.] 

Pascalis " found spirochajtas in 10 cases of syphilis 
and none in nonspecific lesions. 

Ploeger " gives a summary of the lesions in which (S'. 
pallida has been found, but says it has not been proved 
the cause of syphilis. He states that observers should 
look for red blood cells in films, as the spirochrotas are 
often found with one end in contact with a red cell. 

Levy-Bing" reports that injections of gray oil acted 
specifically and very rapidly upon ;S'. pallida. In a non- 
treated patient, spirochietas were numerous, but six or 



38 Amkrican Medicike 



DIGEST OF MEDICAL LITERATURE 



fJAKPABY «, 1906 
LVOL. XI, No. 1 



seven days after the first injection of oil they were very 
rarely seen and a week after the second injection they 
had almost completely disappeared. S. refringens, 
though much diminished in numbers, was still numer- 
ous, having diminished parallel with, but less rapidly 
than the patHda. Levy-Bing believes the influence of 
the mercury, and not the course of natural cure, caused 
the disappearance of the spirochjetas. Notes of six cases 
are given. 

Babes and Panea'" studied three congenital syphilitic 
children, 1 to 4 weeks old, and found S. pnUkla in 
lymph-nodes, the liver, suprarenal bodies, and the 
blood. All organs and tissues showed the effects of 
syphilis. In one hemorrhagic case the blood presented 
some of the characters of leukemia. 

Hoffmann'' found on the surface of three ulcerating 
carcinomas, one of the cervix and two of the skin, 
spirochsetas distinguished with difficulty from the pallida, 
though some fine morphologic points sufficed to differ- 
entiate them ; they were not found in metastatic nodules. 
He also found Bacillus fusi/ormis, some forms of which 
were sickle shaped or spiral, suggesting the possibility 
of them being developmental forms of spirochtetas. 

Rille" furnishes a summary of findings to date, with 
bibliography. 

Gordon '' failed to find spirochietas in the cerebro- 
spinal fluid of eight patients suffering from cerebrospinal 
syphilis or tabes, with a clear history of syphilis ; also 
in the fluid of two persons with initial lesions. 

Davidsohn -' describes staining S. pallida with kresyl- 
violet. 

Neoggerath and Stahelin" found ty pic S. pallida in 

the blood of three cases of secondary syphilis ; 1 cc. of 

blood from the lobule of the ear was mixed with 10 cc. 

■ of ifo acetic acid and centrifugalized, the spirochretas 

being found in the sediment. 

Harvey and Bonsfleld,'* in studying mucous lesions 
of syphilis, failed to find spirochjetas in films stained by 
Leishman's stain, but found them in three of four pre- 
pared by Giemsa's method. They also found with them 
fusiform bacilli resembling those in Vincent's angina. 
The writers say this symbiosis is worthy of notice, be- 
cause such bacilli have been found with spirillums in py- 
orrhea al veolaris. Possibly the spirillums may be formed 
from large bacilli by longitudinal fission, as Leishman 
describes in the development of the parasite of kala 
azar. 

Bandi and Simonelli " found S. pallida in three of 
five cases of secondary syphilis ; the examined material 
consisted of blood from roseolous patches and scrapings 
from the bases of papules. Later,'" they report finding 
the organism within the epithelial cells of mucous mem- 
branes. This suggests the possibility of it being a cell 
parasite. 

Rizzo and CipoUina'' found, in the juice of enlarged 
inguinal lymph-nodes of four cases of secondary syphilis, 
S. pallida in large or small numbers. It was also pres- 
ent in one flat condyloma, but was not demonstrated in 
papules, macules, the spleen, or circulating blood. The 
writers obtained from one mucous patch, fine, tortuous 
connective-tissue elements which resembled the spiro- 
chseta. 



Spitzer'" had no difficulty in obtaining positive re- 
sults in the lesions of syphilis, including ulcerating and 
nonulcerating gummas. Other lesions were invariably 
negative. He warns against relying upon the finding of 
S. pallida, except by experts, in lesions of the prepuce, 
as other organisms resembling it are there present. 
Some links necessary to prove the spirochrota the cause 
of syphilis are still lacking. 

Dudgeon " recommends a modification of Leishman's 
stain for demonstrating S. pallida. 

Reischauer^' found -S'. pallida in large numbers in 
the liver and a few in the spleen and lungs of a stillborn 
syphilitic child; none were found in the kidney or 
blood. 

Rille and Vockerodt '' say that S. pallida has been 
found in 22 different localized forms of syphilitic lesions 
in 14 patients ; they believe they are the first to find it 
in extragenital primary lesions. They do not support 
the statement of Wechselmaun and Lowenthal that 
mercury modifies the spirochicta, as they found perfect 
forms after the use of mercurial inunctions for ten days. 
Some forms of the pallida are regarded as indistinguish- 
able from the refringens. Farther reports of cases should 
include a description of the clinical phenomena and also 
state the duration of the syphilitic infection. 

Bandler'* and Shennan '^ each give an exhaustive 
review of the literature of the subject. 

Vuillemin,'^ in a communication to the Acad, des 
Sciences, says /S'.pf///(rfaisa protozoon related to that caus- 
ing dourine, and proposes for it the generic name Spiro- 
nema, and for the species, Spirotienia pallidum. 

Mulzer" concludes that <S'. pallida is present as a rule 
in the lesions of syphilis, and not in other lesions or in 
healthy people. Differentiation of the pallida and the 
coarser form is not specially difficult for an expert. 

Kraus and Proutschoff '^ say the spirochseta found in 
smegma, balanitis and condylomas, can be differentiated 
from the typic *S'. pallida. From the investigation of 
lesions in more than 80 human beings and 4 apes, the 
writers conclude that *S'. pallida is absent from healthy 
men and apes, and constantly present in syphilitic prod- 
ucts ; it probably is the exciting cause of syphilis. 

Nigris ^' found in blood from a maculopapular efflores- 
cence on the foot of a syphilitic child of two months, 
both the pallida and the refringens. In the fluid of a 48- 
hour vesicle produced on a healthy portion of the skin of 
this chi^l, the pallida only was found. 

Richards aud Hunt*" found three forms of spirillums 
in scrapings from syphilitic sores and also the fine type 
in the bloody fluid obtained by pricking the spots on the 
abdomen, chest and arm of three persons showing sec- 
ondary lesions of a few days' duration. 

Hirschberg" publishes a formula for Giemsa's stain, 
but the meaning of the first item is not clear ; 
he has found <S'. pallida in the urine of a patient who ex- 
hibited active secondary manifestations. 

Fanoni" has found ;S'. pallida in smears from five 
cases of syphilis, various primary and secondary lesions 
being studied. He gives the technic of staining by the 
methods of Giemsa, Oppenheim and Sachs, and Marino. 

It is not amiss to mention in this connection that 
Siegel" describes a small flagellate protozoon Cytor- 



January 6, 1906"! 
Vol. XI, Mo. 1 J 



DIGEST OF MEDICAL LITERATURE 



[Amkkican Mkdicinf 39 



I 






rhyctes luis found in the blood and tissues, particularly of 
inoculated animals, which he asserts is the specific cause 
of syphilis. 

REPBKENCES. 

1 Deut med. Woch., May 18 and 25, 1905. 

2 C. R. Soc. Biol., T. Iviii, May 20, 1905, pp. 845-847. 
' Ibid., May 27, 1905, pp. 883-884. 

•St. Petersburg Med. Woch., No. 20, 1905. 

5 Berlin klin. Woch., June 5, 1905. 

« Roussky Vratch, June 11, 1905. 

' Miinch. Med. Woch., June 13, 1905. 

sSem. Mfidk-ale, June 21, 1905. 

»Med. News, June 17, 1905. 

'"Brit. Med. Journal, June 10, 1905. See Ed. in American 
Medicine, October 7, 1905, p. 628. 

" Roussky Vratch, June 18, 1905. 

" Deut. med. Woch., No. 26, 1905. 

" Wien. klin. Woch., No. 28, 1905. 

"Miinch. med. Woch., July 4, 1905. 

'^Presse. Med., July 5, 1905. 

'" Jonr. of Infectious Diseases, Vol. ii. No. 3, June 24 1905 

" II Policlinico, July 9, 1905. 

'8 Miinch. med. Woch., July 18, 1905. 

"Le Bulletin Medical, July 12, 1905. 

™ Berlin, klin. Woch., July 10, 1905. 

21 Ibid. 

" Miinch. med. Woch., July 18, 1905. 

" American Medicine, July 22, 1905. 

"Berlin, klin. Woch., July 31, 1905. 

25 Miinch. med. Woch., August 1, 1905. 

=6 Jour. Royal Army Med. Corps, August, 1905. 

" Riforma Medica, July 22, 1905. 

28 Miinch. med. Woch., August 29, 1905. 

29 Riforma Medica, August 5, 1905. 
'"Wien. klin. Woch., No. 31, 1905. 
" The Lancet, August 19, 1905. 
'2 Deut. med. Woch., August 24, 1905. 
" Miinch. med. Woch., No. 34, 1905. 
"Prager med. Woch., No. 34, 1905. 
'5 Scottish Med. and Surg. Journal, September, 1906. 
'« La Syphilis, September, 1905. 
" Berlin, klin. Woch., September 4, 1905. 
'8 Wien. klin. Woch., September 14, 1905. 
'9 Deut. med. Woch., September 7, 1905. 
"The Lancet, September 30, 1905. 
"Jour. A. M. A., October 7. 1905. 
" Med. News, October 7, 1905. 
"Miinch. Med. Woch., July 11 and 18, 1905. 



REVIEW OF LITERATURE 

Clinical and Pathologic Sig:nificance of Balau- 
Jtidium Coli.— R. P. Strong > furnishes notes of 115 
I reported cases, and adds one. Histologic examination 
^Of the intestine was made in seven cases, and in two of 
' them the parasite was found in the tissues. In 90 <i^ of 
the ca.ses diarrhea was a prominent symptom. An ad- 
dendum contains notes of several additional cases, in 
some of which the parasite was found in the tissues. 
Strong believes we should attribute to the balantidium 
the same significance in cases of intestinal disturbance as 
we do to the presence of amebas in cases of dysentery. 
That the balantidium is capable of producing a primary 
erosion of the intestine has not been conclusively demon- 
strated. If such erosion exists from other causes, the 
parasite is certainly capable of continuing it. 

Influence of Postmortem Pntrefaction Upon the 
Agglutinative Power of Bacillus of Eberth.— C. 
Ferrai 2 reports a series of graded experiments which he 
claims are important from at least a medicolegal stand- 
point. The agglutinative power falls in a direct ratio to the 
extent of putrefaftion, and depends also upon tempera- 
ture and other features of environment. Deutsch's 
views are controverted, in the light of results as they 
appear in these experiments, [t.h.e.] 

Some Observations on the Occurrence of Mi- 
crococcus Zymogenes — E. «. Birge' refers to the 
case which was reported by Macf^allum and Hastings, in 
which they isolated this organism from a vegetative 
endocarditis both from the circulating blood and at 

' Bureau of Government Laboratories, Bulletin 26, Decem- 
ber, 1904. 

2 II Policlinico (Rome) 190.'>, fase. No. .35. 

'Johns Hopkins Hospital Bulletin, September, ]fX)5. 



autopsy, and which was pathologic for most of the ordi- 
nary laboratory animals. His own results are at variance 
with those of the above investigators. He has isolated 
from the mucous exudate in the larynx of certain crows 
a micrococcus corresponding morphologically and cul- 
turally with their organism, but in the ordinary labora- 
tory animals large doses had a very slight effect. A 
rennin-like ferment is secreted by the organism which 
does not appear to be affected by small amounts of car- 
bolic add. It can be distinguished from Streptococcus 
pyogenes and from staphylococci by its characteristic cul- 
tural reaction in milk and by its doubtful pathogenicity. 

[II.M.] 

Heteromorphic and Teratologic Forms of Bac- 
teria L. Trincas ' draws attention to the forms 

described by Gamaleia and also to the studies of Naegeli. 
The element of microorganismal adaptability is large, 
and the species must always be regarded as greatly 
modifiable. For experiments, the writers advise some 
addition to the usual medium, and have found that 
caffein gives remarkable results with B. coti communis, 
B. typhosus, B. paratyphoid, and the different forms of 
B. dysenterm. They soon develop many divergent 
types on agar-agar thus prepared with caffein. Such 
methods can be applied to secure a differential diagnosis 
in ca,ses of atypic diseases, for the branch forms do not 
maintain so rigidly their species, [t.h.e.] 

Microscopic Study of the Lung after Mechan- 
ical, Experimental Asphyxia — Roberto Serratrice,^ 
under the direction of Professor S. Ottolenghi of the 
University Royal, of Rome, has made a series of experi- 
ments on rabbits, three groups of which were respec- 
tively hanged, strangled, and drowned. Ottolenghi has 
called attention to the position of importance held by 
the pulmonary elastic fiber. Results will have a value 
in medicolegal study, and more especially to determine 
whether trauma or a morbid process is responsible for 
the pulmonary disorder. It appears that: 1. Micro- 
scopic examination does not draw any pathognomonic 
distinctions, but is able to supplement effectively the 
study of macroscopic appearances. 2. The salient 
changes noted are : (a) Essential circulatory modifica- 
tions, such as hyperemia, hemoglobinic extravasation, 
and hemorrhagic infiltration into the pulmonary paren- 
chyma, which characterize the forms of hanging and 
strangling. (6) Those changes dependent on the fiber of 
the lung, such a.s alveolar dilation and stretching of the 
bronchioles, even to rupture of the respiratory channels. 
These indicate results of drowning. In the latter group, 
the circulatory changes are virtually limited to paren- 
chymal ecchymosis, while in the former group, true for 
both strangling and hanging, are chiefly those changes 
which appear as restricted zones of emphysema and sug- 
gestive of atelectasis. 3. Between hanging and strang- 
ling the differences microscopically are trifling, but the 
latter death gives rise to zones of a peculiar type of 
interstitial emphysema, while the former inclines to the 
atelectatic variety. 4. The epithelial changes along the 
bronchial channels cannot be differentiated. 5. A posi- 
tive differential can be made between the changes 
occurring in the pulmonary elastic fiber after death from 
pulmonary emphysema, or from some traumatic 
asphyxia, such as is met with in any of the three forms 
herein experimented with, for in the rupture of the 
elastic continuity by disease there is always a modifica- 
tion of the histologic appearances, while in either hang- 
ing, strangling, or drowning one can observe the true 
traumatic dissolution of fiber, [t.h.e.] 



Dr. Zambaco Pacha has devoted the sum of 10,000 
francs towards the organization of a medical congress to 
be held every three years at Athens. 

• II Policlinico (Rome) August 13, ]905. 

"11 Policlinico (Rome) September Medical Section, 1905. 



40 \MBBICAN MkDICINKI 



DIGEST OF MEDICAL LITERATURE 



rJANUARY 6, 1906 
LVOL. XI, No. 1 



CLINICAL MEDICINE 

THE PLACE OF ORIGIN OF ANTIBODIES. 
A CRITICAL SUMMARY. 

BY 

EUGENE LINDAUER, M.D. 

Immunity, the freedom from liability to infectious 
diseases, was first explained by Metchnikoff, when he 
elaborated his "theory of phagocytosis." He said all 
forms of immunity depended upon the activity of the 
body cells, all microorganisms and their products being 
destroyed by it. The bactericidal action of the body 
juices he explained by stating that bactericidal sub- 
stances are dissolved out of the body cells, this action 
being dependent, therefore, also upon the phagocytic 
power of the cell. Buchner, Nuttall, and others disputed 
this, claiming that immunity was due to germicidal 
properties of the juices themselves. Behring's discovery 
of antitoxic serums increased the scepticism regarding 
phagocytosis, and investigations concerning antibodies 
of all kinds have been very numerous, especially since 
Ehrlich published his " Lateral Chain Theory of Im- 
munity." This theory, although attacked by many 
eminent observers, explains more of the phenomena of 
immunity than any hypothesis yet brought forward, and 
must today be considered as the accepted hypothesis of 
immunity. It is founded upon the specific affinities 
existing between toxic and nontoxic substances on the 
one hand, and the body cells on the other. The body 
cells extract from the food particles surrounding them 
such substances as are suitable for their use and are pro- 
vided for this purpose with certain receptors, which, due 
to their chemic composition, combine only with sub- 
stances suitable for the proper maintenance of the cell. 
The food molecule is spoken of as haptophore. Hapto- 
phores suitable chemically for the nutrition of the body 
cells are to be found not only among the food proteids, 
but also among the poisonous proteids circulating 
through the body juices, the result of disease. They 
attach themselves to the receptors just as do the normal 
haptophores of the food. The toxic elementof the mole- 
cule is spoken of by Ehrlich as the toxophore. If the 
toxophorous part of the molecule does not at once kill 
the cell, the receptors thus occupied will be replaced by 
others, and if the stimulation is sufficiently great, some 
of the receptors formed cannot find room on the surface 
of the cells, are extruded and circulate in the blood as 
free antitoxic substances, being still capable to unite 
with haptophores, thus neutralizing toxins ; larger 
amounts of poisons can be recovered from and immunity 
against that particular organism or its toxin exists. 

The fact that antibodies are a product of the reaction 
of the living organism and are actively produced by the 
tissues, and not, as has been stated by some of the 
earlier workers on the subject, metamorphosed toxins, is 
proved by the, following observations : The time when 
sufficient antitoxin is produced to make animals im- 
mune varies in the same species with the same doses; 
pilocarpin, by stimulating the secretory power of the body 
cells, increases the amount of antitoxin formed in the 
same space of time; the blood of actively immunized 
animals has been removed in toto, and thus all the toxin 



has been removed ; within a short time the animal's 
blood contained as much antitoxin as before. 

Among the questions of importance in the domain of 
immunity, few have received more attention than the 
mode of action of the antibodies and the conditions 
under which they are formed ; exact experiments have 
made marked progress possible. The places of their 
formation have also been much discussed and much 
experimental work has been done on this subject. For 
a long time it has been the general opinion that the 
hematopoietic organs are the places of production of the 
antibodies, or, at least, that they are of the greatest 
importance for their production. Some of the investi- 
gators worked with bactericidal substances, others with 
hemolysins, bacterioagglutinins, hemoagglutinins, and 
antitoxins. 

Pfeiflfer and Marx' immunized animals against the 
cholera vibrio, and examined the bactericidal action of 
extracts and emulsions of different organs. They found 
the spleen and bone marrow to be more effective than 
the blood-serum, if the immunization had been brought 
about but a short time ; later the serum was stronger. 
This, the authors believe, proves that the antibodies are 
formed in these organs and not simply stored there. 
Extracts of other organs also showed a weak bacteri- 
cidal action. Wassermann ■' performed the same experi- 
ments with like results, employing typhoid bacilli for 
purposes of immunization. Van Emden' immunized 
rabbits against Bacillus cerogenes ; he then noted the 
agglutination power of the blood-serum and emulsions 
of different organs ; the results were exactly as those 
described above. Jatta* immunized animals against 
the typhoid and Bacillus coli communis, and found the 
splenic extract to be more' agglutinative than blood- 
serum as late as the fourth day of immunity ; after this, 
blood-serum was stronger. Castellani* immunized rab- 
bits against dysentery bacilli and injected cultures of 
this organism, together with splenic extract and blood- 
serum, into the peritoneal cavity of guineapigs; 
the former recovered with more certainty than the 
latter. The agglutination titer of the former was 
higher than that of the latter. Roemer" im- 
munized rabbits against ulcus serpens, with the 
same result. Deutsch ' found the bactericidal action 
of bone marrow weaker, that of spleen sometimes 
weaker, sometimes stronger than blood-serum. Metsch- 
nikoff and Besredka * say that hemolysins originate in 
the organs, forming and containing macrophages, spleen, 
and lymph-glands. Tarassevitch ^ also found these organs 
more powerful than blood -serum. Doemeny'" found theop- 
posite to be true ; this was true of all organs, even of those 
containing many large mononucleated cells. Inasmuch 
as the normal blood-serum of guineapigs dissolved the 
red corpuscles of dogs, Donath and Landsteiner" argued 
that the discovery of the cell variety of the guineapig, 
which protects dogs against these hemolysins, would dis- 
cover the cells which manufacture the antibodies. They 
were able to immunize dogs by injections of serum, 
leukocytes, and erythrocytes. Blumreich and Jacoby" 
and Jakuschewitch " removed the spleen of guineapigs, 
induced artificial infection, and compared them to guinea- 
pigs whose spleens were not removed. The operated 



January 6, 19061 
Vol,. XI, No. 1 J 



DIGEST OF MEDICAL LITEKATURE 



(American Medicine 41 



animals bore the infections better, their serum was more 
bactericidal, the leukocytcsis smaller, and the serum less 
hemolytic. Removal of the spleen after the infection did 
not seem to have any influence. Brezina'* injected 
guineapigs with serum of chickens who had been 
treated with emulsions of spleen and bone marrow of 
guineapigs. He found that such animals' serum had a 
weaker agglutinating power toward Bacterium coli com- 
mune than that of guineapigs not thus treated. Forss- 
mann '* injected botulism toxin into goats and found a 
larger amount of antitoxin formation (neutralization) 
when injections were made subcutaneously than when 
made intravenously ; this he considers argues for a local 
production of antibodies. He had the same results 
where diphtheria organisms were injected. There was 
a production of antibodies after both injections, but it 
was less marked after intravenous injections, and he 
supposes the same to be true for other diseased antibodies. 
The maximum of the antitoxin curve after subcutaneous 
injections was reached on the fifteenth day, after intra- 
venous injections on the tenth. Forssmann says all 
tissues have an antibody value and the curves of all 
tissues differ. Dzierkowski " says that inasmuch as 
toxin absorbed into the circulation is at once neutralized 
by the antitoxin contained in it, the blood is not stimu- 
lated into antitoxin formation ; very little of the toxin is 
neutralized by the subcutaneous tissues and therefore 
they form much antitoxin, this being absorbed into the 
blood ; he used horses for his experiments. Wassermann 
and Citron" say that all the cells of the organism are 
capable of formation of antibodies ; the cells of the 
lymphatic apparatus are apparently the most important, 
because the substances injected are absorbed rapidly into 
the circulation, and therefore come into very intimate 
contact with the cells of the hematopoietic system. They 
injected living cultures of typhoid organisms into rabbits 
intrapleurally, intraperitoneally, and intravenously ; 
exudates were then produced by aleuronat injections, 
and the fluids thus produced compared with the blood- 
serum. In almost all instances they found a greater 
amount of antibodies in the pleural and peritoneal fluid 
than in the blood-serum ; the few exceptions which they 
noted they explained by very rapid absorption of the 
antibodies. Neisser and Wechsberg'* injected animals 
subcutaneously and intraperitoneally with staphylolysin 
inducing immunity ; the former injections resulted in 
large infiltrations and large amounts of antibodies ; the 
latter gave no free antibodies at all. The importance of 
the subcutaneous tissues for the production of antibodies 
in local injections has been commented on by Ehrlieh. 

Ehrlich's summary of the question, as expressed by 
his disciple, Roemer,'" is that the antibodies are formed 
wherever toxic haptophores can find receptors with 
similar chemic affinitives. Some microorganisms act 
only upon organs important to life; their toxophores 
react upon the colls very easily and therefore the 
receptors are replaced with difficulty, and little if any 
free antitoxin is found in the blood after the attack is 
recovered from. Other poisons find sensitive cells in 
tissues beside organs important to life and large amounts 
of antibodies are produced ; example : experiment of 
Forssmann. Roemer introduced abrin in gradually 



increasing doses into the conjunctival sac, thus inducing 
immunity; an emulsion of the treated conjunctiva pro- 
tected mice against abrin ; an emulsion of the other 
conjunctiva did not, thus showing that antibodies are 
formed locally by the conjunctival cells. The spleen 
and bone marrow showed a larger amount of antibodies 
up to a certain time (four days) than did the blood- 
serum. He found that animal organisms not sensitive 
to toxophores may produce antibodies in large amount, 
and that a small amount of the toxin may produce large 
amounts of antitoxin. Ehrlieh and Roemer suggest the 
possibility that the cells of the vessel walls may be the 
structures from which the antibodies originate ; he says 
they do not simply fufll static functions, but are living 
organs undoubtedly important for the composition of the 
lymph and blood. 

In addition to references mentioned in text, the 
article, McFarland, J., International Clinics, 1904, iv, 
293, should be referred to. 

REFERENCES. 

1 Zeitschrift fiir Hygiene, 1898, xxvii, 272. 
<2 Berliner klinische Wochenschrift, 1898, xxxv, 2C9. 
' Zeitschrift fur Hygiene, 1899, xxx, 19. 

* Zeitschrift fiir Hygiene, 1900, xxxiii, 185. 
5 Zeitsclirift fiir Hygiene, 1901, xxxvii, 381. 

* Die Eiirlich'sclie Seitenkettentlieerie, etc., Wien, 1904. 
' Annales de I'Institute Pasteur, 1899, xiii, 689. 

8 Annales de I'Institute Pasteur, 1!XK), xlv, 470. 

5 Aunales de I'Institute Pasteur, 1902, xvi, 127. 
'" Weiner klinische Wochenscrift, 1902, xxxix, 1025. 
" Zeitschrift fiir Hygiene, 1903, xliii, 552. 
'2 Zeitschrift fiir Hygiene, 1898, xxix, 419. 
"Zeitschrift fiir Hygiene, 1904, xlvii, 407. 
'* Wiener klinische Wochenscrift, 1905, xlii, 905. 
" Centrablatt f'lir Bacteriologie, etc., 1905, xxxviii, 463. 
i» Archives de Sciences blologiques de St. Petersburg, vols, v 
and ix. 

" Zeitschrift fiir Hygiene, 1905, 1, 331. 

18 Zeitschrift fiir Hygiene, 1S)01, xxxvi, 299. 

1' Loc. cit., p. 04. 



A Medical College for the United Provinces of 
India. — A great effort is being made to establish a med- 
ical college and hospital for the United Province's in 
commemoration of the visit of the Prince and Princess 
of Wales to India. The proposal was mooted 35 years 
ago, but has until recently been dropped. Already some 
5 lakhs have been subscribed. The scheme includes a 
hospital, class-rooms, a library,^ museum, laboratory, and 
residence for students and professors. The whole of the 
United Provinces seem awakened to the necessity for 
this iastitution and the cities are vying with each other 
in the generosity of their support. If the public show a 
sufficient patronage toward its establishment the govern- 
ment will contribute to its maintenance and develop- 
ment. 

The Plague Epidemic in India. — The epidemic 
of plague is following along lines similar to those of 
previous years. A temporary increase in the mortality 
of one week is followed by a small setback the next, 
but there is little doubt of the indications of a further 
development with the new year. For the week ended 
November 18 there were 2,826 deaths recorded. The 
local figures are: Bombay Province, 1,420; Madras 
Province, 51 ; Bengal, 223 ; United Provinces, 272 ; the 
Punjab, 233 ; Burmah, 66 ; the Central Provinces, 213 ; 
Mysore State, 104 ; Hyderabad State, 92 ; Central India, 
143 ; and Kashmir, 3. These figures show an increase 
in six provinces and a small diminution in the deaths 
for the others. Continued efforts are being quietly made 
to popularize inoculation, but the numbers who accept 
this protection are so small as to have no appreciable 
effect on the local outbreaks. 



42 American Mkdicinki 



INDEX OF LEADING ARTICLES 



r.lANUARV 6, 1906 

LVOL. XI, No. 1 



INDEX OF LEADING ARTICLES. 

The Journal of the American Medical Associa- 
tion, Vol. xlv, No. 27, December 30, 1905. 

"Pathologic Physiology a Neglected Field." W. S. 
HalIj, Chicago. 

"The Abrupt Onset of Typlioid Fever." M. Maxges, 
.New York. 

" Counting Blood-Platelets." J. H. Pratt, Boston. 

"The Diameters of the Normal and the Phthisical 
Chest." W. A. Bessesen, Chicago. 

" Myoma of the Esophagus." J. Bryant, Jr., Boston. 

" Report of Committee on Proprietary Medicines." O. 
T. O^siiORNE and C. S. N. Hallberg, Chicago. 

" Acute Hemorrhagic Pancreatitis." C. F. New, In- 
dianapolis. 

"Poisoning by the Papaw (Asimina triloba)." M. A. 
Bakber, Lawrence, Kansas. 



Medical Record, Vol. 68, No. 27, December 30, 1905. 

"Chronic Discharge in Organic and Functional Dis- 
orders of the Deep Urethra." John M. Thomp- 
son, Boston, Mass. 

" Epilepsy the Strangest Disease in Human History." 
William P. Spratling, Sonyea, N. Y. 

" The Occurrence of Bacteria in the Normal Adult 
Intestine, with Special Reference to the Etiology of 
Enterotoxismus." Harris A. Houghton, New 
York. 

" Osteosculpture ; and Original Method for the Study of 
Osteology." H. C. Gifford, Syracuse, N. Y. 

"Dermoid Ovarian Cyst Simulating Floating Kidney." 
A. E. Isaacs. 

"The Alkalinity of the Blood in Febrile Toxemia." 
.Frederick W. D' Evelyn, San Francisco. 



Bostbn Medical and Surgical Journal, Vol. cliii. 
No. 26, December 28, 1905. 

<'The Muscle-Splitting or McBurney Incision in Acute 
Appendicitis, with or Without Abscess. The Course 
and Result in 75 Consecutive Cases." L. R. G. 
Crandon and David D. Scannell, Boston. 

"The Municipal Control of Tuberculosis." Edward 
O. Otis, Boston. 

" Two Cases of Anatomic Anomaly of the Large Intes- 
tine." Samuj:l Robinson, Boston. 



Medical News, Vol. 87, No. 27, December 30, 1905. 

" The Essentials of Successful R6ntgen-Ray Therapy." 
Charles Lester Leonard, Philadelphia. 

"The Communicability of Cerebrospinal Meningitis and 
Probable Source of Contagion." Charles Bol- 
duan and Mary E. Goodwin, New York. 

" Thiosinamin in the Treatment of Tinnitus Aurium." 
S. McCcllagh, New York. 

"Some Observations on Leukoderma." F. Bobbins, 
New York. 



"The Medical Department of Bilibid Prison and Some 
of the Diseases Among the Prisoners." W. R. 
MouLTON, Bilibid, P. I. 

"Infection of the Gallbladder in' Typhoid Fever." S. 
P. Kramer, Cincinnati, O. 



New York Medical Journal, Vol. Ixxxii, No. 27, 
December 30, 1905. 

" Annual Address of the President of the Medical Society 
of the County of New York." Floyd M. Cran- 
DALL, New York. 

" Eclampsia : A Review of the More Recent IVIethods of 
Treatment, with the Results." Lewis M. Gaines, 
Wake Forest, N. C. 

" A Study of Contagion." Walter S. Cornell, Phila- 
delphia. 

" Nonoperative Treatment of Prolapsus Uteri." Kate 
Campbell Mead, Middletown, Conn. 

"Neurasthenia Among Blonds in the Southwest." V. 
E. Watkins, U.S. A., Plattsburgh Barracks, N. Y. 

" The Recognition of Eyestrain by the General Practi- 
tioner." Clarence Payne Franklin, Phila- 
delphia. 

"Typhoid Fever in Infants." S. D. Williamson, 
Malone, N. Y. 



The Lancet, Vol. 169, No. 27, December 23, 1905. 

"The Albuminuria of Pregnancy and the Kidney of 
Pregnancy." G. F. Blacker. 

"Chronic Pancreatitis, Probably Starting in an Acces- 
sory Pancreas." A. W. Mayo Rob.son. 

" The Surgical Treatment of Tuberculous Glands in the 
Mesentery." Edred M. Corner. 

"Carcinoma of the Testicle." Alex. G. R. Foul- 

ERTON. 

" Huntington's Chorea and Dementia." Robert Jones. 
"Some Remarks on the Prevention of Appendicitis." 

W. J. Tyson. 
" Raw Meat Alimentation in Tuberculosis." R. W. 

Philip. 
"Ventral Fixation of the Uterus by a New Method." 

W. G. Richardson. 



British Medical Journal, December 23, 1905. 

"Retrospects and Prospects Relating to University 
Life." Reginald Harrison. 

" Modern Fashions in Surgerj'." J. Lynn Thomas. 

" The Value of the Sigmoidoscope in the Diagnosis Be- 
tween Primary and Secondary Colitis." P. Lock- 
hart Mummery. 

" Wandering Spleen ; Hemorrhage Within the Capsule ; 
Splenectomy ; Recovery." Charles P. Childe. 

" Puerperal Eclampsia." Reginald Dunlop. 

" The Surface Tension of Urine in Health and Disease, 
with Special Reference to Icterus." W. D. Don- 
nan and F. G. Donnan. 

" Detachment of the Retina." James A. Craig. 



American Medicine 



David Riksman 
Aller G. Ellis 
M. B. Hartzeli, 
Norman B. Gwyn 
Hblen Murphy 



GEORGE M. GOULD, Editor 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Rugh 
Bernard Kohn 
John W. Churchman 



G. C. C. HOWARD, Managing Editor 



COLLABORATORS 
A. O. J. Kelly 

WiLMER KRnSEN 

John Knott 
Lawrence Hendee 
A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. Rhein 
J. Coles Bkick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pyle 
D. Braden Kylb 
Eugene Lindaueb 
Alfred Gordon 



Published Weekly at 1321 Walnut Street Philadelphia by the American-Medicine Publishing Company 



Vol. XI, No. 2. 



JANUARY 13, 1906. 



5.00 Yearly. 



Sanitary couditious in the canal zone come in 
for their share of criticism in an article by Mr. Poultney 
Bigelow.' It is painful reading at best, and were it not 
for the author's wellknown pessimism as to most things 
in the land of his birth it would be alarming. The 
optimist sees the doughnut and tlie pessimist sees the 
hole, but Mr. Bigelow can only see the size of the hole. 
Of course things are bad or were bad, and of course it is 
a tropic country with swampy towns and wretched 
sanitation or none at all, and of course the official 
reports mention only what has been done to improve 
matters. There was dreadful mismanagement at first, 
so bad, indeed, that the whole commission was dis- 
missed, but things did improve for a while. It cannot 
be expected that everything can be corrected at once, 
yet there does seem to be a good beginning. 

Yellow fever has practically gone, according to 
the October report, and the report also shows that no 
October on record shows such good results ; that is, no 
October in which so many nonimmunes were on the 
Isthmus. Yet one gains an idea from Mr, Bigelow's 
article that the official reports do not give the proper 
impression, and, moreover, that nothing but mistakes 
have been made — such as government hotels not used 
or usable because built on swamps, and a sewer system 
which backs sewage up into houses when it rains ; that 
laborers are uncared for and get sick unnecessarily ; that 
there is room for more cleaning so as to need less disin- 
fecting ; that laborers have not received the promised 
pay and are deserting ; that there is the worst kind of 
political jobbery, and so on through many counts. Many 
of these accusations may be just, for they sound like the 
aftermath of the first awful blunder of sending down 
thousands of men before there were any buildings for 
them to live in, or food to eat or water to drink. 

That things are not so bad as stated in this de- 

pressing article must be hoped ; but if they are, it i s 

' " Mismanagement at Panama," and published in The In- 
dependent of January 4. 



good to have some one who is able to say so. The state- 
ments of disgruntled returning employes have always 
been discredited, but they have said essentially the same 
as Mr. Bigelow, only in more bitter terms. As there is 
no evident ax to grind of personal grievance in this 
case, it is the part of wisdom to listen to him. Some of 
the ofiicial reports are so self-laudatory as to give color 
to his strictures, and it would have been better if they 
were not so complaisant and could have told what future 
work was needed and planned. It now seems quite 
likely that Congress will insist upon a rigid investiga- 
tion to sift the fact from fiction, and place the whole 
matter on a basis of law. The present plan does not 
work well — that's the only lesson we can draw until the 
facts are printed in full. 

Government management of business affairs has 

received a violent blow by the history of the Panama 
Canal to date. The functions of government are vastly 
different from those of the citizens individually or in 
little groups or corporations. Governments have the 
sole duty of protecting the units from each other and 
from outside harm, and it collects money for this pur- 
pose and no other. It coordinates activities, does not 
take part in them. When it goes into life insurance, or 
railroad management, or canal building, it is out of its 
natural sphere, and is doing work for which it has no 
organization and no agents. Brains big enough to man- 
age big affairs are generally doing big things for big pay, 
and will not leave the work for a government job. That 
leaves appointments for the small-brained failures, and 
they are not given intelligence by accepting a govern- 
ment position. If they have failed at one place they will 
fail in office, too. For these reasons, municipal owner- 
ship of street railways is proving very expensive and 
impractical. There is a general idea that if the govern- 
ment will only take hold, the thing is done at once, and 
done well. The only kind of work which stands such a 
test is that done by officials who hold life positions and 



44 



AMKBicAN Medicine] 



EDITORIAL COMMENT 



CjANtTARY 13, 1906 
Vol. XI, No. 2 



who cannot be injured for doing their duty. Occasion- 
ally men of large calibre are found in those positions 
who do well, as in the engineer corps of the army. Yet, 
as a rule, it is far preferable to do as New York City did 
in its subway — find out what is wanted and then pay a 
contractor to do it all. This may be the only solution 
of the awful muddle at Panama, for it now looks as 
though the government could not do the work and will 
be compelled to give it to a contractor after it has found 
out what it really wants. The matter has a painful 
medical side, for there is every prospect of future sani- 
tary trouble if there is really as much unreported sick- 
ness as Mr. Bigelow states there is under the present 
government control. Nevertheless, we do hope he has 
looked at the zone through blue glasses, and that it is 
not really as bad as he thinks it is. 

Football injuries have been described in the Bos- 
ton Medical and Surgical Journal of January 4 by Drs. E. 
H. Nichols and H. B. Smith, who had professional care 
of the Harvard football squad during the last season, and 
it is grewsome reading. There were 150 men in the 
squad at the beginning of the season and these are the 
injuries they had received in prior years in the game : 

Sprain of thumb, 9 ; bruise of knee, 1 ; cuts, various 
places, usually head, 5 ; bruised shoulder, 31 ; disloca- 
tion of elbow, 1 ; injury to back, 2 ; synovitis of knee, 
39 ; sprain of ankle, 42 ; concussion, 7 ; fractured wrist, 
2 ; dislocation of knee, 1 ; fractured rib, 4 ; dislocation of 
shoulder, 3 ; contusion of chest, 1 ; fractured clavicle, 7 ; 
ruptured muscle, 7 ; fractured arm, 4 ; injury to eye, 1 ; 
sprain of wrist, 3 ; ruptured internal lateral ligament of 
knee, 1 ; dislocation of thumb, 1 ; fractured toe, 1 ; broken 
nose, 16; fractured olecranon, 1 ; dislocation of ankle, 1 ; 
broken foot, 1 ; sprained toe, 1 ; fractured ankle, 2 ; frac- 
tured carpus, 3 ; fractured elbow, 2 ; dislocation of outer 
end clavicle, 5; fractured finger, 8; injury to kidney, 1 ; 
fractured fibula, 1 ; teeth out, 1 ; total, 216. 

Of the 150, about 50 soon dropped out ; and of the 
remaining 100, only 70 constituted the real players, and 
they, of course, received the most of the injuries recorded 
during the past season, as follows: 

Sprained thumb, 1 ; fractured fibula, 1 ; cuts (required 
stitches), 12 ; bruises, 6 ; dislocation of elbow, 1 ; teno- 
synovitis tendo-achillis, 1 ; dislocation of xiphoid carti- 
lage, 1 ; injury to back, 9 ; synovitis of knee, 3 ; sprained 
ankle, 13 ; strained muscle of side, 2 ; crushed fingers, 1 ; 
contusion of knee, 1 ; contusion side, 1 ; fractured rib, 5 ; 
rupture of internal lateral ligament knee, 1 ; dislocation 
of shoulder, 2 ; concussion, 19 ; ruptured muscle, 6 ; dis- 
located semilunar cartilage, 10 ; contusion of elbow, 1 ; 
compound dislocation of fingers, 2 ; traumatic valgus, 1 ; 
fracture of zygoma, 2 ; torn ear (sutured), 3 ; broken 
nose, 7 ; fracture of rim of pelvis, 4 ; fractured clavicle, 
1 ; bruised hip, 2 ; fracture of semilunar of wrist, 1 ; dis- 
location of acromial end clavicle, 11 ; fractured finger, 4 ; 



broken second cervical vertebra, 1 ; dislocation of inner 
end of clavicle, 1 ; rupture of biceps of leg, 1 ; middle 
meningeal hemorrhage, 1 ; hematoma of ear, 2 ; fracture 
of metacarpal bones, 3 ; sprained elbow, 1 ; total, 145. 

Concussion of the brain happened to one or more 
players in every game except two, and the cases were of 
every grade of severity, from mere hysteric irrespon- 
sibility or confusion to complete coma. Loss of memory 
of events prior to the game was quite common and the 
normal mental state was only gradually restored. There 
was one case of cerebral hemorrhage. After reading this 
terrible indictment of the game it is quite evident that 
the human system is not built strongly enough to stand 
anything near the strains inflicted on it. 

The severity of the iDjuries is best determined 
by the length of time the players were disabled to such 
an extent that they could hot play. During the season 
the injured men were unfit for play 1,057 days, or nearly 
three years' time for one man, and they were unable to 
attend to scholastic duties for 175 days. At the end of 
the season 35 men were still suffering from their injuries, 
and many more who thought they were recovered were 
known to be still disabled more or less permanentlv. 
The writers conclude that football results in incompar- 
ably more injuries than any other game, and that there 
are more of them than is generally believed. As a rule, 
the injuries come in a " pile " and not in open play, and 
niost of them are inherent in the game and unavoidable. 
They conclude, also, that the game does not develop the 
best kind of men, the only survivors being the beefy 
types with sluggish nerves which do not convey pains. 
Indeed, a certain amount of anesthesia is needed to play 
the game — a poorly developed pain sense, such as we see 
in savages— and it is quite evident that the average 
civilized man with normal sensibilities is positively 
unfit to play it. In addition, the authors state that the 
number of injuries is too great for mere sport which 
should not require the constant presence of surgeons ! 
The real injury to the players is not even touched upon, 
for there is nothing said of the ultimate results of the 
cardiac hypertrophy due to the training; nor is there 
anything said about the possibility of premature arterio- , 
sclerosis from the muscular strains, nor the nerve 
exhaustion of beefy athletes, which so often results in 
alcohol or drug habits, nervous breakdown or increased 
susceptibility to infections, particularly tuberculosis. 
The after-history of these men will be interesting patho- 
logic studies. 

The great objection to football is a much deeper 
matter than the mere injuries to a few students — it 
is a fundamental defect of the educational system. 



JANUARY 13, 1906"! 

Vol. XI, No. 2 J 



EDITORIAL COMMENT 



[AMEBICAKT MEDICIWB 45 



Of course it is wrong to put anyone in training at any 
time, to create a physiologic cardiac enlargement wiiich 
remains to plague him in after life, but to place the 
^ growing boy under this regimen is nothing short of 
1 criminal. No college sport should require "training," 
I no matter how much practice is needed, and no game 
I should single out a few very abnormal men. Sports are 
I necessary parts of youthful life, the essentials of a child's 
: education, indeed, and every one must take part in them 
I to educate the nerves— not to deaden them. Games are 
J normal only when they cultivate perceptions to accuracy 
land quickness, but never should they put the tissues to 
their maximum allowable strain. The only u.se of the 
present game seems to be to aflFord relaxation to those on 
i the grand stand— pale-faced boys who should be at some 
I game themselves instead of rooting for the beef of the 
college. The gambling and commercialism do not con- 
[cern the medical side of the matter, but are features 
Ihaving a distinctly pernicious psychologic effect upon 
f boys at the very age they can be most injured. We hope 
[that these dreadful Harvard revelations will be the final 
[argument to convince educators and college faculties 
I that they must wake up to their duty to regulate sport. 
I" Play of animals and children is res^lly a means of educat- 
ing or exercising other parts of the nervous system than 
[the mere memory, which seems to be the main thing 
^drilled in our college youths. If some play is beneficial 
-and there does not seem to be any doubt on that point, 
^hen it must be utilized and encouraged for every stu- 
aent, and not so utterly ignored and allowed to degen- 
|€rate to a form which is injurious. 

English football comes in for considerable praise at 
the hands of Ralph D. Paine in the Century Magazme, 
^and it is apparent that he is correct. As played abroad, 
the game is merely one of the ways of getting young men 
outdoors to exercise and does not require " training " to 
play it ; indeed, it is the training itself, for it is the 
natural and normal method of play in which young 
animals of all kinds indulge. It is said that the young 
Briton thinks that in no game is the work of long prepa- 
ration worth the cost, and in addition, there is no fun in 
it that way, for it becomes business and not play. 
Finally, it is considered wrong to specialize in sports. A 

oan who trains to do one thing, like putting the shot or 

printing, may be an addition to a college track team, 
knd a team composed of such specialists may make big 

oints in contest with another team in which there are 
^nly good all-round athletes, but the specialist is injur- 

Qg himself, in that he is compelled to neglect parts of 

^Ws physique to his own future injury. This period of 

life must be devoted to general development of both 



body and mind as a preparation for the specialization 
which comes later in the serious business of life. Then 
again, there are not so many men injured in English 
football and a death is a rare accident. We have killed 
27 in the last season, so it is said, not a very large mor- 
tality in comparison with the numbers who played the 
game, but just exactly 27 too many. 

Japanese naval surgery was described by Surgeon- 
General Shigemichi Suzuki in a most interesting paper 
read before the Association of Military Surgeons ' at their 
last annual meeting in Detroit. He does not mention any- 
thing new in the way of surgical technic or operative inter- 
ference, for the keynote of all their methods is to do as 
little as possible. The report will no doubt be keenly 
disappointing to those who have read the popular litera- 
ture, which seems to have imputed superhuman intelli- 
gence to the little oriental surgeons. Suzuki reports 
that they foresaw fhe impossibility of securing surgical 
asepsis on a warship in battle. Even in peace it is diffi- 
cult and operations are never performed on shipboard 
except in cases of extreme urgency. Hence, the junior 
Japanese surgeons were ordered to make the wounds as 
clean as possible, dress them, and then leave them alone. 
Easily removed splinters of shell or wood were removed, 
of course, but no search was made for them. Their plans 
were devised with a view of removing the wounded to a 
real hospital on shore in the quickest possible time. The 
results of the system were very good indeed. Of the 
men who were struck, about half were killed outright — 
an illustration of the carnage of naval warfare when 
there are any casualties. Of the 1,791 wounded, only 
117 died, though but 647 had been hurt sufficiently to 
require hospital care, and of these only 32 died. 

Conservative surgery in war has had a brilliant 
vindication and the results should open the eyes of those 
who constantly write of the necessity of abdominal 
operations on the dirty battlefield. In modern land 
warfare also, the idea now seems to be to get the 
wounded back to where they can be properly treated. 
Suzuki wisely stated that it was wrong to spend a long 
time over a few cases and let the others wait, conse- 
quently they were all treated alike with temporary 
dressings. A modification of this rule is just as appli- 
cable in land battles. The details of the surgical technic 
he mentions are familiar to every ambulance surgeon — 
indeed, to every general practitioner. He marred his 
report by saying that they were convinced of the 
immense value of the aseptic treatment of wounds. 
American surgeons were convinced of it so long ago that 

'Journal of the Association o( Military Surgeons for No- 
vember, 1905. 



46 [American Medicike 



REVIEWS 



[January 13, 1906 
Vol. XI, No. 2 



if, at this late date, there are any who are not yet con- 
vinced, it is doubtful whether they can ever be con- 
vinced of anything. Taking it all in all, there is little 
or nothing to be learned from Japanese naval surgery, 
except the great lesson to do as little as possible in dirty 
surroundings. The idea of compelling the sailors to 
bathe and put on clean clothing prior to battle was new 
and excellent and no doubt greatly reduced the number 
and severity of cases infected by dirty clothing carried 
in by projectiles. In other professional matters it is evi- 
dent that the Japanese have borrowed from the Occident 
and invented but little. 

Interesting pathologic solution of a problem of 
£89,000 An interesting example of the possible in- 
fluence of contact of clinical pathology with forensic 
procedure was demonstrated in the Newcastle Law 
Courts (England) on November 18. A Mr. John 
Lockie, shipowner and ex-M. P., was placed in the 
dock on the charge of misappropriating £89,000 from 
shipping companies of which he had been the managing 
director. The trial had not proceeded far when it was 
observed that the defendant was in a fit. He was car- 
ried out of court, and examined by Drs. Clay and Hope, 
who testified that he was suffering from a paralytic 
seizure, and was but partially conscious, so that com- 
plete (mental and physical) rest was absolutely necessary. 
Judge Darling then said that it was impossible to pro- 
ceed with the case, as the whole question of fraud could 
be solved only by the explanations which nobody but 
the defendant himself could give. Legally, the trial 
could go on in his absence, but it was perfectly obvious 
that the jury could form no definite conclusion. Even if 
the defendant recovered by next day, to put him in the 
witness box would only bring on the risk of another 
seizure, which might be more serious or even fatal. 
Under such circumstances he could not think of dealing 
with the man, and would have to discharge the jury and 
bring that particular trial to an end. It depended on 
the state of defendant's health whether he was to be put 
on his trial again and when. On the question of bail, 
his lordship said that Mr. Lockie was to be taken to the 
infirmary, and in the circumstances he would not keep 
him till bail was found. Accordingly, he had nothing 
to do but to discharge the jury from giving a verdict. 
(He directed that the defendant should be bound over in 
£100 in his own recognizance to appear at the next 
Assizes if called upon.) 



BOOK REVIEWS 



American Association for the Advancement of 
Science and the societies affiliated with it held a meet- 
ing at New Orleans last week. Professor W. G. Farlow, 
of Harvard University, gave the presidential address, 
his subject being " The Popular Conception of the Scien- 
tific Man at the Present Day." 



Textbook of Insanity By Dr. R. Von Kkafft- 

Ebin«, late Professor of Psychiatry and Nervous 
Diseases in the University of Vienna. Author- 
ized translation from the last German edition by 
CHARiiKS GiIjUert Craddock, M.D., Professor 
of Diseases of the Nervous System in the Marion- 
Sims-Beaumont College of Medicine, medical 
department of St. Louis University, St. Louis, 
Missouri. With an introduction by Frederick 
Peterson, M.D., President of the New York 
State Commission in Lunacy. Philadelphia: F. 
A. Davis Company, 1904. 

While this work is essentially one for the careful and 
advanced student of insanity, certain chapters appeal 
strongly to the general practitioner. For example, those 
chapters devoted to the consideration of general therapy 
are full of important suggestions. The work is largely 
a clinical one, and contains the histories of 81 cases in 
detail, illustrating as many different mental states. 
While Krafft-Ebing acknowledged the existence of 
hebephrenia, as described by Kahlbaum and Hecker, he 
did not feel justified in regarding it as a peculiar form of 
disease. Dementia prtecox, as described by Kraepelin, 
includes hebephrenia, as well as other morbid mental 
states, and is acknowledged by many alienists as a clini- 
cal entity. It is rather surprising, therefore, to find no 
mention of this symptom-complex, and only a brief 
mention of hebephrenia in this book. The chapters on 
the development of psychiatry from ancient times down 
to the present are valuable and full of interest. This 
translation is, without doubt, an extremely important 
addition to the English literature of insanity. It is to 
be regretted that there is so much fine printed matter in 
the book. It is quite proper that the details of the cases 
should be in smaller type than the general text, but 
when subdivisions of the subject are placed in much 
finer print than the general text it becomes tiresome, 
and at times makes the reading laborious. 

A Manual of Chemistry.— By Arthur P. Luff, 
M.D., and Frederic J. M. Page, B.Sc. Third 
edition, revised throughout. Chicago: W. T. 
Keener & Co., 1905. 

The third edition of this work brings it up to our 
present knowledge of chemistry and again makes it a 
valuable help for students of medicine. The composi- 
tion of various substances lately coming into use as drugs 
is furnished under organic chemistry. Though the 
pages are small, no space is wasted and a great deal of 
information is crowded into the 538 pages of text. 

The Diseases of Society.— By G. Frank Lydston, 
M.D. Philadelphia and London: J. B. Lippin- 
cott Company, 1904. 

In this book of 614 pages the author attacks the vice 
and crime problem in his usual vigorous manner and 
presents the subject in a way that impresses the reader 
with the earnestness of his convictions derived from a 
long study of its various phases. He discusses the prin- 
ciples of evolution in their relation to criminal sociology, 
the etiology of social diseases in general, the relation to 
them of neuroses, the chemistry of social diseases, sex- 
ual vice and crime, genius and degeneracy, and the 
therapeutics of social disease with special reference to 
crime. The influence of the slum in social disease is 
depicted and special emphasis is put upon the newspaper 
as a cause. Lydston punctures effectually the " wild 
oats" theory and shows how often this is responsible for 
after-lives of crime. Licensing of prostitution or any 
recognition of it as an institution he regards as abso- 



January 13, 1906"! 
VOL. XI, No. 2 J 



REVIEWS 



(Ahericak Medicinb 47 



lutely inimical to the welfare of society ; he also advo- 
cates asexualization of rapists, of whatever color. In 
the chapter on genius and degeneracy, the author gives 
a list of persons including Dickens, Burns, George Eliot, 
Byron, Lamb, Coleridge, Johnson, and Victor Hugo, all 
of whom showed indubitable evidences of degeneracy ; 
not every one will agree with this. As a whole the 
book presents in a very forcible, though somewhat 
rambling manner, topics that are of the greatest impor- 
tance to society and which are too often overlooked. It 
is well worth reading by every adult, whether or not he 
is specially interested in the problems of sociology. 

Manual of Clieniistry.— By W. Simon, M.D., Ph.D. 
Eighth edition, thoroughly revi.sed. Lea Brothers 
& Co., Philadelphia and New York, 1906. 

But little need be said of the eighth edition of a book 
which has met the favor accorded Simon's Chemistry. 
It has been delayed for a year in order to incorporate 
the changes necessitated by the new Pharmacopeia and 
thus render it of service to students of pharmacy as well 
as of medicine and dentistry. Many portions of that 
part dealing with organic chemistry have been practi- 
cally rewritten. It continues to be one of the sterling 
works on this subject. 

The Principles of Bacteriology. — By A. C. Abbott, 
M.D. Seventh edition, enlarged and revised. 
Lea Brothers & Co., Philadelphia and New York, 
1905. 

The seventh edition of this wellknown book includes 
the later methods in bacteriolog.y which have proved 
valuable, as well as the recent additions to the science 
itself. Advances in the domain of infection and immunity 
are given special importance. The book now contains 
674 pages, with 100 illustrations, of which 24 are colored. 
It well deserves a continuation of the popularity accorded 
the previous editions. 

A Manual on Acute Poisoning and First Aid to the 
Injured. — By John W. Wainwkight, M.D. 

A. R. Pelton, New York, 1905. 

This little pocket manual is one that may be of some 
use to the practitioner and one the reviewer should 
judge of great u.se to the housewife. The arrangement 
of the subject is good, the first chapter being devoted to 
the general principles of treatment, the poisons them- 
selves being well arranged under their special types. 
The part devoted to " First Aid to the Injured " is very 
brief and perhaps more attention given to after-treat- 
ment, rather than to simple "First Aid," than is war- 
ranted. 

A Textbook of Diseases of Women. — By Charles 

B. Penrose, M.D., Ph.D. Fifth edition, revised. 
Philadelphia, New York, London : W. B. Saun- 
ders* Co., 1904. 

The fifth edition of Dr. Penrose's wellknown text- 
book contains many additions which have been rendered 
necessary by the progress of the specialty. A complete 
index and 225 illustrations add to the value of the work. 
The advocates of conservative gynecology will be pleased 
to note that several pages have been devoted to the pes- 
sary and its uses for tlie treatment of mobile retrodis- 
placements of the uterus. The author has carefully con- 
sidered the technic of the special gynecologic operations 
and has emphasized the necessity for perfect asepsis in 
all operations. The gynecologist, who is debarred from 
the use of antisepsis during a peritoneal operation, must 
rely altogether upon the a.sepsis of his technic. The 
general practitioner often forgets that the genital 



tract of a woman communicates directly with the pe*'i- 
toneum, and so frequently becomes careless of his asepsis 
in vaginal and intrauterine manipulation. Penrose 
emphasizes the fact that just as much care must be taken 
in minor gynecologic operations as in the major pro- 
cedures. 



Handbook of Anatomy. —By James K. Young, M.D. 
Second edition, revised and enlarged. F. A. 
Davis Company, Philadelphia, 1905. 

The author has in this manual brought out a work of 
a larger scope than the quiz-compend, but still fulfilling 
some of the requirements of the latter. The subject- 
matter is presented in a clear and concise manner. The 
illustrations are well chosen, those on the nervous system 
being particularly so. Those who wish such a type of 
work on anatomy will find this manual to more than 
fulfil their requirements. 



The Diagnosis of Diseases of Women. — By Palmer 
FiNULEY, B.S., M.D. Second edition, enlarged 
and revised. Lea Brothers & Co., New York 
and Philadelphia, 1905. 

The second edition of this work is more complete 
than the earlier edition. The chapters on special 
diagnosis referable to the malignant growths, also those 
devoted to the urinary system, are quite complete and 
up-to-date. The book, as a whole, is one of high standard 
and great usefulness, both as a textbook and a reference 
book. The author may be complimented for adhering in 
his subject-matter to diagnosis and not wandering off into 
the realms of operative treatment and technic, so often 
the faults of works on diagnosis. The book is well illus- 
trated and is graced with a good index. 



The Treatment of Diseases of the Eye. — By Victor 
Hancke. Translated by J. Herbert Parsons, 
B.S., D.Sc., F.R.C.S., and George Coat.s, M.D., 
F.R.C.S. Chicago : W. T. Keener & Co., 1905. 

Dr. Hancke's small work contains an epitome of 
general ophthalmic science, with special reference to the 
methods of treatment employed in Professor Fuch's 
clinic. A surprising amount of material has been 
included in the 220 closely printed pages, and the volume 
will find a prominent place in the large list of reliable 
elementary works on ophthalmology. Many of the 
newer methods are fully described and most of the new 
remedies are mentioned, bringing the work quite up to 
date. 



The Johns Hopkins Hospital Reports. Volume 
VII. Baltimore: The Johns Hopkins Press, 
1904. 

This volume contains 548 pages and includes eight 
articles : " The Connective Tissue of the Salivary Glands 
and Pancreas with Its Development in the Glandula 
Submaxillaris," by J. M. Flint; "A New Instrument 
for Determining the Minimum and Maximum Blood- 
pressures in Man," J. Erlanger; "Metabolism during 
Pregnancy, and the Puerperium," J. M. Slemons ; "An 
Experimental Study of Blood-pressure and Pulse-pres- 
sure in Man," J. Erlanger and D. R. Hooker; "Ty- 
phoid Meningitis," R. I. Cole; "The Pathologic 
Anatomy of Meningitis Due to BaoilluH ti/phostis,^' W. 
G. McCallum ; "A Comparative Study of White and 
Negro Pelves," T. F. Riggs ; "Renal Tuberculosis," G. 
Walker. All of the articles are thorough and painstak- 
ing in character, as are always found in this publication, 
and hence valuable contributions to the subjects con- 
sidered. 



48 American Medicine! 



EEVIEWS 



C January i3, 1908 
Vol. XI, No. 2 



Memoranda of Poisons. — By Thomas Hawkes Tan- 
ner, M.D., F.L.S. Tenth revised edition by 
Henry Leffmann, A.M., M.D. Pliiladelphia : 
P. Blakiston's Son & Co., 1905. 

This is the best concise statement of its subject in the 
marlcet. The reputation of the editor for accuracy, 
lucidity, and conciseness prepares us to find these char- 
acteristics in the booli, and we are not disappointed. As 
a matter of course, a duodecimo volume of 175 pages is 
not an extensive treatise upon toxicology, and the title 
of the book indicates as much. Physicians and phar- 
macists need just such a brief, trustworthy guide for refer- 
ence and refreshment of memory in emergencies. 



Studies of the Psychology of Sex. — By Havet.ock 
EijLis. F. a. Davis Company, Philadelphia, 1905. 

In this volume Ellis gives the results of his studies 
of the sensations of touch, smell, hearing, and vision in 
relation to the psychology of sex. This work represents 
the first of five volumes, in which the various phases of 
the subject will be treated. Some interesting, although 
perhaps not very important, conclusions are summar- 
ized. In works treating of the sexual life there is a ten- 
dency to appeal to the interest of the reader in a some- 
what morbid manner. This book is, in the main, rather 
free from this objection, although in the appendix there 
are a number of histories of psychopathic conditions, in 
which the cases are given in too great detail. The scien- 
tific value of the cases would not suffer if, in relating the 
histories, the author had appealed less to the morbid 
imagination of the reader. On the whole, the book is 
well written, and will be found most interesting. 



Legal Medicine. — By Frank W. Draper, A.M., 
M.D. Fully illustrated. W. B. Saunders & Co., 
Philadelphia, New York, London, 1905. 

Dr. Draper's experience of 26 years as medical ex- 
aminer of Boston (during which time the causes of 8,000 
deaths were investigated), together with his long exper- 
ience as a teacher, have eminently fitted him to write a 
book on legal medicine. The work is an excellent one, 
and he ably discusses the various questions which arise 
in medicolegal medicine. It is to be regretted that he 
has omitted chapters on toxicology and the medicolegal 
relations of insanity, as no textbook on legal medicine is 
complete without these. The chapter on the medico- 
legal relations of human blood is unusually good. Dr. 
Draper takes the conservative view of the value of the 
serum test for blood in medicolegal examinations. This 
work is a valuable one to the general practitioner and to 
the medical student, who will find the subject (with the 
two exceptions above stated) fully and clearly described. 



A Manual of the Diseases of Infants and Children. 

— B.v John Ruhrah, M.D. Philadelphia, New 
York, and London : W. B. Saunders & Co., 1905. 

Dr. Ruhrah has outlined the therapeutics of infancy 
and childhood in a way that cannot fail to make for this 
work a place of first importance in its field. Explicit 
instructions for dosage and prescribing are given, and a 
number of useful prescriptions are appended. The sub- 
ject of infant feeding is taken up in detail. A very 
valuable feature consists in the many references to pedi- 
atric literature, so selected as to be easily accessible by 
the student, enabling him to ascertain the sum of knowl- 
edge on any given disease. The volume is of service to 
the busy practitioner, but it is of special value to the 
student, enabling him to grasp quickly the more impor- 
tant parts of the subject of pediatrics, and furnishing 
him with a rapid reference book for clinical use. 



Manual of Psychiatry.— By J. Rouges DeFursac, 
M.D. Authorized translation from the French 
by Rosanoff, M.D. First edition. New York : 
I. Wiley ; London : Chapman & Hall, Limited, 
1905. 

DeFursac has employed the classification of Kraepelin 
with some modifications. Before discussing the diff'er- 
ent varieties of insanity the author treats in a general 
way the etiology, symptomatology, method of examina- 
tion, and therapeutics. The subject is briefly and clearly 
treated, and the work will be found most useful to the 
general practitioner and the medical student. In the 
translation the French insanity law has been wisely 
omitted, and the translator has introduced some clinical 
records from cases at the Long Island State Hospital, at 
King's Park, New York, a.s satisfactory translation of 
the French cases was not possible. The print is unusu- 
ally good and clear, and generally the book is published 
in a most creditable form. 

BOOKS RECEIVED. 

[Prompt acknowledgment of books received will be made in this 
column, and from time to time critical reviews will be made of those 
of interest to our readers.! 

Surgical Diagnosis.— By Albert A. Berg, M.D., Ad- 
junct Attending Surgeon to Mt. Sinai Hospital, New York. In 
one 12irio volume of 543 pages with 215 engravings and 21 full 
page plates. Cloth, §3.25 net. Lea Brothers & Co., Philadel- 
phia and New York. 

Physical Diagnosis.— By Egbert LeFevre, M.D., Pro- 
fessor of Clinical Medicine and Therapeutics in the University 
and Bellevue Hospital Medical College, Attending Physician 
to Bellevue Hospital and to St. Ijuke's Hospital, New York. 
New second edition, thoroughly revised and much enlarged. 
In one 12mo volume of 479 pages with 102 engravings and 6 full 
page plates in black and colors. Cloth, 82.25 net. Lea Brothers 
& Co., Philadelphia and New York. 

Pathogenic Microorganisms: A Manual of Pathogenic 
Microorganisms, including Bacteria and Protozoa.— By Wil- 
liam Hallock Park, M.D., Professor of Bacteriology and 
Hygiene in the University and Bellevue Hospital Medical Col- 
lege, and Director of the Research Laboratory of the Depart- 
ment of Health, New Y'ork. New second edition, enlarged and 
thoroughly revised. In one octavo volume of 5o6 pages, with 
lfi5 engravings ami 4 full page plates in black and colors. 
Cloth, $3.75 net. Lea Brothers <fe Co., Philadelphia and New 
York. 

Faulty Diction.— By Thos. H. Russell, LL.B., Editor-in- 
Chief of Webster's Imperial Dictionary. Geo. W. Ogilvie <fe 
Co., Chicago, 111. 

The Medical Society of the Borough of the Bronx, 
October, 1905. 

Old Lamps and New, and Other Verse.- By Edward 
WiLLARD Watson, M.D. H. W. Fisher & Co., Philadelphia. 

The Blues (Splanchnic Neurasthenia): Causes and 
Cures. — By Albert Abrams, A.M., M.D. (Heidelberg), 
F.R.M.S., Consulting Physician, Denver National Hospital for 
Consumptives, etc. Illustrated. Second edition, enlarged. 
E. B. Treat & Co., New York, 1905. Price, 81.50. 

Radiotherapy in Skin Diseases. — By Db. J. Bblot, 
with a preface by Dr. L. Brocq, Physician to Broca Hospital, 
Paris. Translated by AV. Deane Butcher, M.R.C.S., Surgeon 
to the London Skin Hospital. Only authorized translation 
from second French edition. With 13 plates and 28 illustrations. 
Rebman Company, New York and London, 1905. 

Gumption :, The Progressions of Newson Newr. — By 
Nathaniel C. Fowlkk, Jr. Small, Maynard <fe Co., Boston, 
1905. 

Progressive Medicine: A Quarterly Digest of Advances, 
Discoveries, and Improvements in the Medical and Surgical 
Sciences. — Edited by Hobart Amory Hare, M.D., Professor 
of Therapeutics and Materia Medica in Jefferson Medical Col- 
Ipge of Philadelphia, etc. Assisted by H. R. M. Landis, M.D., 
Visiting Physician to the Tuberculosis Department of the 
Philadelphia Hospital, etc. Vol. iv, December, 1905. Lea 
Brothers & Co., Philadelphia and New York, 1905. Price, $6.00 
per annum. 

Annual Report, Bureau of Health, Philadelphia, 1904. 
Dunlap Printing Company, Philadelphia, 1905. 

Year Book of Legislation. — Edited by Robert H. 
Whitten, Sociology Librarian, New York State Education 
Department, Albany, 1905. Price, ?1.00. 

Organotherapy.- By H. Batty Shaw, M.D. (London), 
F.R.C.P., Lecturer In Therapeutics, University College, Lon- 
don, etc. Illustrated. W. T. Keener & Co., 1905. Price, ?1.75 
net. 



January IS. 19061 
Vol. XI, No. 2 J 



AMEEICAN NEWS AND NOTES 



fAMERiCAN Medicine 49 



AMERICAN NEWS AND NOTES 



GENERALi. 

Havana Free of Yellow Fever. — ^ According to 
official report, the last case of yellow fever has disap- 
peared from Havana, and there are no suspicious cases 
under observation. 

Patent Medicines in the British Provinces. — 

Owing to the death at Victoria (British Columbia) of an 
infant from laudanum contained in a patent medicine, 
the Provincial Government has appointed a commission 
to investigate the sale of such medicines. 

Lepi'osy in the Philippines. — A recent monthly 
report of the Board of Health of the Philippine Islands 
cites the fact that a total of 3,683 lepers is now living 
in the archipelago. They are scattered throughout the 
various provinces, Cebu, with 675 afHicted, having the 
largest number. Only one province is entirely free from 
the disease. 

An Appointment to the United States !Leper 
Sanatorium. — Dr. Walter R. Brinckerhoff, instructor 
in pathology at the Harvard Medical School, has been 
offered the position in Hawaii to take charge of the 
United States leper sanatorium, which is to be estab- 
lished there. He graduated in the Harvard Medical 
School in 1902, and is only 27. 

Philippine Board of Health. — The monthly 
reports reach this country nearly three months after 
publication in Manila, but are unusually worth study 
for data. The prevention of smallpox is one of the 
tasks that keeps them busy, and a systematic distribution 
of vaccine virus is carried on. Between June 30 and 
August 1 there were distributed in Manila and 21 
provinces 190,150 units of vaccine virus. 

Assistant Surgeoncies Vacant.— There are 24 
vacancies in the junior grade of the medical department 
of the army, and an additional vacancy will occur by 
virtue of the r&signation of Lieutenant James F. 
Edwards during the present week. The next ex-amina- 
tion of candidates for appointment as assistant surgeon 
in the army will take place on April 1 or May 1. About 
that time also there will be commissioned as permanent 
officers in the corps the 17 provisionally accepted candi- 
dates who pas.sed the examination last year and who 
are under instruction in Washington. 

United States Pharmacopeial Business Affairs. 

— An edition of the Pharmacopeia in the Spanish lan- 
guage will no doubt be one result of the recent meeting. 
A committee consisting of Professor J. P. Remington, 
chairman of the Committee of Revision ; Charles E. 
Dohme, chairman of the Board of Trustees ; and Dr. H. 
_0. Wood, president of the United States Pharmacopeia 
anvention, was appointed to make the preliminary 
rrangements for an edition of 2,000 copies. With a 
lew of bringing the Pharmacopeia to the direct attention 
^ medical students, it was decided to present to the pro- 
ssors of materia medica in the medical colleges compll- 
jentary copies. 

The American Association for the Advancement 
'Science has decided upon a special meeting at Ithaca, 
L Y., on June 28, and the next regular meeting in New 
fork City December 27, 190(5. The following officers 
^ere elected by the general council : President, W. H. 
Yelch, of Baltimore ; vice-presidents — section on mathe- 
aatics and astronomy, Edward Kasner, of New York ; 
liysies, W. C. Sabine, of Cambridge, Mass.; chemistry, 



Clifford Richardson, of New York ; engineering, W. R. 
Warner, of Cleveland ; geology, A. C. Lane, of Lansing, 
Mich.; sociology, E. C. Conklin, of Philadelphia; botany, 
Daniel T. McDougall, of Washington ; anthropology, 
Hugo Munsterberg, of Cambridge, Mass.; social and 
economic science, C. A. Conant, of New York ; physi- 
ology and experimental medicine, Simon A. Dexter, of 
New York. 

The National Association for the Study and Pre- 
vention of Tuberculosis. — Announcement is made by 
the Board of Directors of the National Association for 
the Study and Prevention of Tuberculosis of the pre- 
liminary arrangements for the second annual meeting of 
the association, which will be held in Washington, May 
17, 18, and 19, 1906. Two new sections have been estab- 
lished, one on surgical tuberculosis and the other on 
tuberculosis in children. The officers of the sections are 
as follows : Sociologic Section : Chairman, Mr. William 
H. Baldwin, Washington, D. C. ; secretary, Miss Lilian 
Brandt, New York. Clinical and Climatologic Section : 
Chairman, Dr. Vincent Y. Bowditch, Boston, Mass. ; 
secretary. Dr. Edwin A. Locke, Boston, Mass. Patho- 
logic and Bacteriologic Section : Chairman, Dr. Edward 
R. Baldwin, Saranac Lake, N. Y. ; secretary. Dr. Hugh 
M. Kinghorn, Saranac Lake, N. Y. Section on Surgical 
Tuberculosis: Chairman, Dr. W. W. Keen, Philadel- 
phia, Pa. ; secretary. Dr. Robert G. LeConte, Philadel- 
phia, Pa. Section on Tuberculosis in Children : Chair- 
man, Dr. W. P. Northrup, New York ; secretary. Dr. 
Roland G. Freeman, New York. 

Miscellaneous. — Dr. Alexander Graham Bell has 

given $75,000 to the Volta Bureau, of Washington, 
D. C, as a memorial to his father. Prof. Alexander Mel- 
ville Bell. The bureau was established by Dr. Bell with 
the object of increasing the diffusion of knowledge 
relating to the deaf and dumb. — Dr. John Nicholas 
Mitchell, of Philadelphia, was provisionally elected 
secretary of the State Lunacy Commission. The provi- 
sion is that he resign from the State Board of Charities, 
of which he is now a member. He is also a member of 
the Lunacy Commission. The election was to fill the 
vacancy made by the recent death of George I. McLeod. 
The position pays $3,000 a year. He was graduated 
from the University of Pennsylvania and later from 
Hahnemann Medical College. From 1888 until 1895 he 
was professor of obstetrics in Hahnemann Medical Col- 
lege. He has been a member of the State Board of 
Charities since 1903.— Anne E. Peale, of Philadelphia, 
made the following charitable bequests : To the Penn- 
sylvania Hospital, $5,000, to endow a free bed for a 
female patient in the department of the insane. To the 
Friends' Asylum for the Insane, at Frankford, $7,000. 

Uniformity in Naval and Military Medical 
Equipment. — The Surgeon-Generals of the Army and 
of the Navy have suggested that a joint board be con- 
voked for the purpose of adjusting the methods and 
establishing uniformity in the equipment of the medical 
branches of the naval and military services. Many 
medical officers of both services take a keen interest in 
the proposition and it is understood that President 
Roosevelt has already expressed his sympathy with the 
movement. It is likely the joint board, composed 
entirely of medical officers of the Army and Navy, will 
soon be ordered to meet in Washington. It is realized 
that there should be greater uniformity in medical equip- 
ment. This is regarded as fully as important as equip- 
ping the armed forces of the country with identical types 
of weapons and ammunition, and the same rules which 
argue in favor of uniformity in that class of equipment 
apply with equal directness to the equipment and train- 
ing of the medical departments of the army and navy. 
The board will give special attention to the subject of 



60 Amkrican Medicinei 



AMERICAJ^ NEWS AND NOTES 



C January 13, 190 
Vol. XI. No. 2 



uniflcation of duties, the education of line ofHcers in 
sliip, camp, and field sanitation, and the special instruc- 
tion of the enlisted men, notably in the application of 
the flrst-aid dressings. It is proposed to bring before 
the board new methods which have been suggested from 
various sources, to try the devices recommended at dif- 
ferent times, and to work out the plans of organization. 
It is probable that the joint medical board will be re- 
quired to work iu conjunction with the naval general 
board and the army general staff, and says the Army 
and Navy Ilegister, it is destined to have a far-reaching 
and eminently practical effect upon military and naval 
administration generally, and to lead to a better, because 
more efficient, equipment of the medical departments. 

EASTERN STATES. 

Massachusetts Hospital for Epileptics. — The 

trustees have submitted their annual report for the year 
ending September 30, 1905, from which the following 
statistics are taken : Number of patients September 30, 
1904, 459 ; since admitted : sane (8 from visit, 3 from 
escape), 102 ; insane (5 from visit, 2 from escape), .57 ; 
total, 618; discharged and on visit: sane — much im- 
proved, 12; improved, 10; not improved, 13; died, 11; 
on visit, 15 ; escaped, 2 ; total, 63 ; insane — recovered, 1 ; 
much improved, 1 ; improved, 5 ; not improved, 2 ; died, 
13 ; transferred, 4 ; on visit, 7 ; escaped, 1=34 ; total, 97 ; 
number of patients remaining September 30, 1905, 521 ; 
daily average of patients, 490.23; per capita cost (per 
week), $4.56. 

Milk Coniiuissloii Proposed. — ^A committee which 
was appointed on December 20 reported to the meeting 
of the Suffolk branch of the Massachusetts Medical 
Society that a milk commission should be appointed for 
Boston. This commission should consist of five mem- 
bers, says the report, appointed from physicians who are 
members of the Suffolk branch of the society, said com- 
mittee to be empowered to furnish experts in veterinary 
matters and in bacteriology, free of charge, the experts 
to give certificates to producers and dealers whose plants 
or premises are found to be in accordance with all proper 
requirements. It is believed that many producers and 
dealers will be glad to meet the requiremjents in order to 
obtain the proposed certificate of pure milk which the 
commission will have the power to grant. Discussion of 
the report was postponed to a general meeting on April 
30. 

White River, Vt., Medical Association has 

adopted a resolution that after January, 1906, no mem- 
ber of the association shall accept the position of club, 
society, or organization physician, or agree to do any 
medical or surgical work for any club, society, or 
organization at a less rate than the regular or customary 
charges for like services rendered by other physicians 
in the same locality for patients not members of club, 
.society, or organization ; also that in no case shall any 
physician agree to attend the families of the members of 
such club, society, or organization at half price or a less 
price than the regular rate. Nothing in this resolution 
shall be construed as preventing any member from 
attending the worthy poor at a less rate or to give free 
service to those who are too poor to pay anything. Any 
violation of this by-law shall be considered unprofes- 
sional conduct, and it shall be the duty of the censors to 
expel such member from the association, when proof of 
such conduct shall be presented to them. 

NEW YORK AND VICINITY. 

The Harvey Society. — The fifth lecture in the 
Harvey Society Course will be given by Prof. W. H. 
Park at the New York Academy of Medicine on January 
20, at 8.30 p.m. Subject: "A Critical Study of Serum 
Therapy." 



Hospital on Steamship Brasile.— The new steam- 
ship Brasile of La Voce Line will arrive at New York 
on January 12, and be placed in the New York-Mediter- 
ranean service. The vessel has a hospital with 50 beds, 
an ambulatory and operating room, a pharmacy, a dis- 
infecting apparatus, and a complete service of hot and 
cold baths. 

The Health of New York The Board of Health 

report for last week last showed 357 cases of contagious 
diseases in the city. Of this number there were 206 cases 
of measles. There were 123 in Brooklyn, and 62 in Man- 
hattan. Because the institution had been quarantined 
on account of measles, the authorities of the Hebrew 
Infant Asylum, 907 Eagle Avenue, Bronx, had to turn 
away a child suffering from pnuemonia. 

New York Neurological Society. — At the annual 
meeting, held on January 2, 1906, the following officers 
were elected for the ensuing year : President, Dr. Joseph 
Fraenkel ; first vice-president, Dr. Adolf Meyer ; second 
vice-president. Dr. J. Ramsay Hunt ; recording secre- 
tary, Dr. Edwin G. Zabriskie ; corresponding secretary. 
Dr. F. K. Hallock ; treasurer, Dr. G. M. Hammond ; 
councillors, Drs. M. Allen Starr, Charles L. Dana, Joseph 
Collins, J. Arthur Booth, and William M. Leszynsky. 

Yerkes Hospital in Bronx. — The great hospital 
provided for in the will of the late Charles T. Yerkes, 
the traction promoter, who died in New York City last 
week, will be built at once. It will be located in the 
borough of the Bronx. This announcement is made by 
Dr. J. E. Janvrin, who says that a beginning will be 
made just as soon as the estate of Mr. Yerkes is settled, 
instead of waiting until after Mrs. Yerkes' death, as 
provided in the will. The projected hospital is entirely 
Mrs. Yerkes' own idea. 

The Committee on the Prevention of Tubercu- 
losis of the Charity Organization has sent out a large 
number of letters to the medical profession of the city of 
New York calling attention to the consequences arising 
from the practice of sending the poor tuberculous to such 
States as Arizona, Colorado, and California. Extensive 
experience has taught us that, difticult as it may be for 
a poor man to recover from tuberculosis in New York, he 
is better off among his friends and relatives, where there 
are more adequate hospital and dispensary facilities, 
than he is far from home, where he is thrown entirely 
upon his own resources and where the great number of 
tuberculous willing to work at the lowest wages make 
the finding of employment, especially of suitable em- 
ployment, almost impossible. Favorable results from 
climate can hardly be looked for unless at least $10 per 
week can b&spent for board and lodging. The stranger, 
who has spent a large part of his savings on railroad 
fare, soon finds himself without work, living in the 
poorest rooms, eating the scantiest and cheapest foods. 
The practice of advising the removal to other climates 
thus defeats its own aims and casts upon the charity of 
other communities a burden which they should not and 
cannot sustain. The committee invites the cooperation 
of the medical profession in preventing persons suffering 
from tuberculosis from being sent to other States unless 
(a) they are physically able to work and have secured in 
advance a definite assurance of the opportunity to per- 
form work of a proper character at wages suflScient for 
their suitable support ; or (6) unless they have at their 
disposal at least $250 in addition to railroad fare. 

PHIIiADEIiPHIA, PENNSYLVANIA, ETC. 

The new maternity building of the Presbyterian 
Hospital was dedicated last week with religious services. 
The cost of the building, which is a four-story brick 
structure, was paid with a gift of $42,670 from an anony- 
mous friend of the hospital. The money was given in 



.1 



January 18, 1906-| 
VOL. XI, No. 2 J 



FOEEIGN NEWS AND NOTES 



rAHEBICAN HbDICINS 61 



1902. The new department of the hospital is thoroughly 
equipped with every modern convenience, including 
operating room, six private bedrooms and ten ward beds. 

SOUTHERN STATES. 

Vaccinating Party in Baltimore. — Owing to the 
discovery of a case of smallpox on Bruce street, in the 
negro quarter, 28 physicians and two police sergeants 
with a squad of men were sent to the spot and vac- 
cinated nearly 500 negroes who had been exposed to the 
infection. 

The Smith County (Texas) Medical Society has 

changed its method of work and will begin giving a 
series of monthly postgraduate courses in medicine, to 
which every physician in the county is cordially invited. 
The first program is : Clinic on Tuberculosis, G. G. Bell, 
J. C. Smith, and A. B. Garland ; Clinic on Heart Dis- 
eases, J. S. Christian, W. A. Crook, and J. C. Davis ; 
Clinic on Diseases of Kidneys, A. S. Jarvis, W. W. 
Shoemaker, and Albert Woldert; Clinic on Diseases of 
the Skin, A. P. Baldwin, Mitch Walker, and W. B. 
Johnson. 

WESTERN STATES. 

" The Alkaloidal Clinic," beginning with the Jan- 
uary issue, has changed its name to The American Journal 
of Clinical Medicine. Several additions have been made 
to the editorial force. 

Park Sanatoriums for Chicago. — The establish- 
ment of tent sanatoriums for the care of infants in each 
of the small parks in the city is to be a feature of next 
summer's philanthropic work in Chicago. 

Bovine Tuberculosis. — All the cattle have been re- 
moved from Angel Island, near San Francisco, by order 
of General Funston, commanding the Department of 
California, because bOfo of the animals were found to be 
affected with tuberculosis. 

Ohio State Board Aiding Physicians. — The Ohio 
State Board of Health has extended its field of usefulness 
by undertaking bacteriologic examinations free of charge 
to physicians. Sputum of suspected tuberculous indi- 
viduals and diphtheria and typhoid fever material may 
be presented for examination, but the privilege does not 
extend to physicians in whose cities the Board of Health 
maintains a laboratory. 



FOREIGN NEWS AND NOTES 



GENERAIi. 

Paper versus Slates.— English educational and 
litary authorities are discussing the advisability of 
bstituting cheap paper and pencils for slates in schools. 
le Lancet is strongly in favor of paper and pencils. 

[The Relation of Population in Ireland. — Accord- 

' to the annual report on births, deaths, and marriages 

flreland during 1904, the natural increase of popula- 

recorded, or the excess of births over deaths, was 

L298. The loss by emigration amounted to 36,902. 

_ A New Hospital for Vienna. — Vienna is consider- 
ng the establishment of a hospital, which will cover 
' '• about 2,400,000 square feet of ground and cost in the 
J- I neighborhood of $8,000,000. The institution will com- 
11' prise 40 buildings which will be utilized for clinical and 



hospital purposes, and offices and residences for the staff". 
There will be 2,300 beds and each patient will be allowed 
about 1,000 square feet of space. 

The Health of London. — During last week 1,460 
deaths were registered, including measles, 45 ; scarlet 
fever, 13; diphtheria, 21 ; whoopingcough, 25 ; enteric 
fever, 4 ; and 14 from diarrhea. The deaths from all 
causes correspond to an annual rate of 16.3 per 1,000. 
In Greater London 1,996 deaths were registered. In the 
"outer ring" the deaths included 6 from diphtheria, 5 
from measles, 3 from whoopingcough, and 1 from 
diarrhea. 

Annual Deathrate of Ireland. — The average annual 
deathrate represented by the deaths registered during 
the week ended December 9, 1905, in the 21 principal 
town districts of Ireland was 20.5 per 1,000 of the popu- 
lation, which was estimated at 1,093,959. The lowest 
rate was recorded in Newry, viz., 4.2, and the highest 
in Newtownards, viz., 28.6 per 1,000. In Dublin and 
suburbs 168 deaths were registered, including diphtheria, 
1 ; enteric fever, 2 ; scarlet fever, 1 ; whoopingcough, 2 ; 
and 28 from tuberculosis. 

Contagion in School Books. — A discussion of in- 
terest has taken place in the French Academy of Med- 
icine on the subject of class books as disseminators of 
contagion in schools, especially in the case of such dis- 
eases as scarlet fever, measles, and diphtheria. Paper 
has long been recognized as a dangerous agent of infec- 
tion, even in tuberculosis, owing to the habit amon^ 
children of turning over leaves with fingers wetted with 
saliva. Dr. Lop, in order to test the extent of danger in 
school books, made long experiments to establish the 
duration of infective power in various bacilli, finding it 
to range from 48 hours for some to 50 days for the Eberth, 
and 103 days for the Koch bacillus. General agreement 
was expressed as to the importance of thorough disin- 
fection of school materials. 

Physicians Go on Strike. — According to the Lon- 
don Express, the entire staff of medical men attached to 
the Exeter Dispensary have decided to strike. Insults, 
tliey declare, have been heaped on them and " the pro- 
fession of medicine degraded by the base calumnies of 
the committee." The trouble has arisen from a proposal 
by the committee to appoint a paid medical officer. In 
1886 the medical staffs of the hospitals of Rome decided 
to strike on a certain day. When the day arrived each 
physician received from the Ministry of War a commis- 
sion in the army, with orders to report for service to gen- 
eral officers who had simultaneously been appointed to 
take charge of the various hospitals. In these circum- 
stances a strike would have been " mutiny." There was 
no mutiny among the new members of the Italian 
army's medical staff. 

Women in Medicine in Germany. — The Deutsche 
medicinische Wochenschrift reports that the fears enter- 
tained some years ago, when women were admitted to 
the study of medicine at the German universities, that 
they would in the course of time prove serious rivals to 
male practitioners, have been proved unfounded. Offi- 
cial statistics, as well as the special investigations of Dr. 
.lohanna Maass, have shown that, since the year 1900, 
only 46 women have been admitted to practice in Ger- 
many, and only 6 have become dentists. Only 31 women 
physicians could still be traced, and of these 9 are 
found in Berlin ; of the 6 women dentists only 1 is in 
the capital city. Of the 31 reporting, 24 confine their 
practice to women and children, 4 are specialists, and 3 
are assistants at medical institutes. State examinations 
were taken by these women in 11 university towns, and 
30 took academic degrees. Four are married. 



52 AMKBICAN MEDICrNE) 



THE PUBLIC SERVICE 



rjANUAKY 13, 1906 

LVoL. XI, No. 2 



OBITUARIES. 

Thomas Clifford Potter, aged 59, January 7, from 
heart disease, at his home in Philadelphia. He was 
graduated from the University of Pennsylvania, in 1871. 
He was consulting physician to the Germantown Hos- 
pital for several years. 

Frank M. King, aged 45, of Damascus, Ohio, com- 
mitted suicide at the home of his brother-in-law in Alli- 
ance, Ohio, January 3. He was graduated from the 
Eclectic Medical Institute, Cincinnati, Ohio, in 1892. 

Daniel Meigs Webb, aged 84, January 1, at his 
home in Madison, Conn. He was graduated from Yale 
Medical School, in 1849. He was one of the oldest prac- 
titioners in New Haven County. 

Harriet Jf. F. Cooke, aged 75, January 6, from 
apoplexy, at her home in New York City. She was 
graduated from the New York Medical College and 
Hospital for Women, in 1868. 

Charles E. Wentz, aged 28, .lanuary 2, from typhoid 
fever, at his home in New Providence, Pa. He was 
graduated from the Medlco-Chirurgical College, Phila- 
delphia, in 1902. 

David R. Davis, January 5, at his home in Lans- 
ford. Pa. He was graduated from the University of 
Pennsylvania, department of medicine, in 1893. 

Thomas W. Simmons, January 1, at his home in 
Hagerstown, Md. He was graduated from Jeiiferson 
Medical College, Philadelphia, in 1861. 

H. Eugene Park, aged 56, January 8, from Bright's 
disease, at his home in Somerville, N. J. 

Foreign. — James Stewart, recently, in Africa. 
Dr. Stewart went to Africa as a missionary. He was 
impressed with the importance of medical knowledge in 
this work and returned U) his native country (England) 
and took the degree of M.D. From 1856 he was con- 
nected with the work at Lovedale in Kaflfraria, and also 
started a mission in memory of Livingstone in Central 
Africa. 



THE PUBLIC SERVICE 



Changes in the Medical Corps of the U. S. Army 

for the week ended January 6, 1906 : 

Lieutenant-Colonel William B. Davis, deputy sur- 
geon-general, leave granted December 16 is extended 
two months. — John R. Hereford, contract surgeon, is 
relieved from further duty in the Philippines Division, 
and upon the expiration of his present leave will pro- 
ceed to Fort Moultrie for duty. — George H. Jones, 
contract surgeon, orders of December 20 are revoked. 
Upon the expiration of his present sick leave will pro- 
ceed to his home, Toledo, O., for annulment of contract. 
— Harry L. Reiter, sergeant first class, Madison 
Barracks, about January 15 will be sent to Fort Myer 
for duty. — Hugo C. Rietz, dental surgeon, is granted 
leave for twelve days from about December 24. — Captain 
William F. Lewis, assistant surgeon, is a-ssigned to 
duty as attending surgeon and examiner of recruits in 
Chicago, 111.— So much of orders, September 11, as 
directs First Lieutenant James I. Mabee, assistant 
surgeon, to proceed to the Philippine Islands on the 
transport to sail from San Francisco, Cal., January 5, is 
so amended as to direct him to report for duty as sur- 
geon of the transport Sheridan during the next voyage 
of that vessel to Manila, P. I. — So much of orders, 
November 8, as directs Captain Henry S. Greenleaf, 
assistant surgeon, to proceed to the Philippine Islands 
on the transport to sail from San Francisco, Cal., on 
January 25, is so amencjed as to direct him to report for 
duty as surgeon of the transport Sherman during the 
next voyage of that vessel to Manila, P. I. — First Lieu- 
tenant Jacob M. Coffin, assistant surgeon, leave 



granted December 16 is extended 15 days. — First Lieu- 
tenant Edward M. Talbott, assistant surgeon, leave 
granted December 23 is extended one month.— George 
B. TuTTLE, contract surgeon, is relieved from duty in 
the Philippines Division, to take eifect at such time as 
will enable him to comply with this order, and will 
proceed on the transport to sail from Manila, P. I., 
about February 15 to San Francisco, Cal., and report by 
telegraph to the military secretary of the army for 
further orders. — Robert B. Irving, sergeant first class. 
Fort Columbus, will be sent to San Francisco, Cal., for 
duty aboard the transport Sheridan. — Harry A. 
Davis, sergeant first class. Fort Myer, immediately 
after reenlistment in the hospital corps, will be sent to 
New York city for duty aboard the transport Kilpatr 
rick. — Alden Carpenter, dental surgeon, is granted 
leave for one month from January 1. — William H. 
Brooks, assistant surgeon, the advancement from the 
grade of first lieutenant to that of captain with rank as 
captain from January 1, 1906, is announced. — Captain 
Henry Page, assistant surgeon, is relieved from duty 
in the Philippines Division, to take effect at such time 
as will enable him to comply with this order, and will 
proceed on the transport to sail from Manila, P. I., 
about March 5, to San Francisco, Cal., and report by 
telegraph to the military secretary of the army for 
further orders. 

Changes in the Medical Corps of the U. S. Navy 

for the week ended January 6, 1906 : 

R. A. Campbell, acting assistant surgeon, appointed 
acting assistant surgeon from January 9, 1906. — G. G. 
Hart, acting assistant surgeon, appointed acting assist- 
ant surgeon from January 10, 1906.— W. N. Block, act- 
ing assistant surgeon, appointed acting assistant surgeon 
from January 12, 1906. — C. G. Herxdon, medical 
inspector, having been examined by a retiring board, 
and found incapacitated for active service on account of 
disability incident thereto, is retired from active service, 
from December 15, 1905, under provision of section 1453, 
revised statutes. — J. F. Murphy, assistant surgeon, 
ordered to naval recruiting station, Omaha, Neb., Janu- 
ary 24. — C. K. Winn, acting assistant surgeon, detached 
from naval recruiting station, Omaha, Neb., January 24, 
and ordered to the naval hospital, W^ashington. — J. T. 
Miller, acting assistant surgeon, appointed acting 
assistant surgeon from January 9, 1906. — L. O. Schetky, 
pharmacist, appointed pharmacist December 27, 1905. 

Changes in the Public Health and Marine-Hos- 
pital Service for the week ended January 3, 1906 : 

R. L. Wilson, passed assistant surgeon. Bureau 
letter of December 1, 1905, granting Passed Assistant 
Surgeon Wilson fifteen days' leave of absence amended 
so as to grant thirteen days' leave only. — T. D. Berry, 
passed assistant surgeon, directed to proceed to Tampa 
Bay Quarantine, Mullet Key, Florida, and assume com- 
mand of the Service, relieving Assistant Surgeon R. E. 
Ebersole. — B. J. Lloyd, assistant surgeon, assigned to 
duty in the office of the United States Consulate at 
Guayaquil, Ecuador. — W. M. Wightman, assistant 
surgeon, relieved from duty at San Francisco Quarantine 
Station, and directed to proceed to Callao, Peru, for duty 
in the office of the United States Consulate. — R. Lyall, 
acting assistant surgeon, granted three days' leave of 
absence from December 26, 1905, under paragraph 210 
of the regulations. — George Neves, pharmacist, 
granted leave of absence for nineteen days from January 
1, 1906. 

Board Convened. — A board of officers was convened j 
to meet at the Bureau December 28, 1905, for the pur- 1 
pose of making a physical examination of an officer of j 
the Revenue Cutter Service. Detail for the Board : [ 
Assistant Surgeon-General J. W. Kerr, chairman ;| 
Assistant Surgeon J. W. Trask, recorder. 



JanUAKY 13, 1906-1 
Vol. XI, No. 2 J 



CORRESPONDENCE 



lAMKRICAN MEniCTNH 53 



CLINICAL NOTES AND CORRESPONDENCE 

[Ctommnnioatlons are Invited for this Department. The Editor Is 
not responsible for the views advanced by any contributor.) 



THIRTEEN LETTERS AND TWO NEWSPAPER 
CUTTINGS. 

BY 

EDMUND F. li. JENNER, 

of Dlgby, N. S. 

(1) St. Ethelreda's Hospital, N. Y. 
Dear Doctor Lee:— I have examined your daugh- 
ter, and I regret to say that I can only confirm your 
family physician's diagnosis. Her left lung is affected, 
but not very badly, the right lung is perfectly sound, 
and if she takes care of herself, she may outgrow the 
trouble completely. I have written Dr. Saunders, 
acknowledging the receipt of his letter, and I will write 
him again, outlining the course of treatment I advise. 

Now I have recommended a winter at , and it is 

somewhat an expensive place to stay at. I am well 
known to the Superintendent of that institution, and if 
you decide to send your daughter there, I will write 
him, and ask that she be taken on special terms. She 
may find the discipline irksome at first, but she will 
soon get used to it, and I have every reason to believe 
that she will return to you in far better health. 

With kindest regards to your wife. 

Yours very sincerely, 

Alfred McGee. 
To the Rev. John Lee, D.D., Morrhuopolis, New Bruns- 
wick, Canada. 

(2) St. Ethelreda's Hospital, N. Y. 
Dear Doctor:— If you receive a letter from one 

John Lee, of Morrhuopolis, Canada, relative to the 
treatment of his daughter in your institution, please 
give her the best room you have, and cut the price in 
two. Send me the bill for one half, and I will settle 
with you. I take a great interest in the case, as Dr. Lee 
was very kind to me when I was a boy, in fact, he 
coached me for my preliminary examination, and did 
not charge me a cent for it. I imagine his congregation 
pays him something like $700.00 a year, and he has to 
keep his family on that, and it would be almost impos- 
sible for him to send the girl to a sanatorium without 
aid. The family history is a bad one, two aunts on the 
mother's side dead of tuberculosis, and her father's 
mother also died from the same cause. Make your 
charge on the old doctor as light as you possibly can, let 
her have everything necessary, and send me your bill 
for the balance, and oblige. 

Yours fraternally, 

Alfred McGee, M.D. 

P. S.— I expect to send you two patients about the 
first of next month. One of them is a hard case, the 
other you will have no difficulty in pulling through. I 
will send details later. 



(3) The — — Sanatorium, Maine. 

Dear Doctor McGee : — I have heard from your 
friend, and I wrote him a pious lie about a partially 
endowed room being vacant. He is to pay $8 per week, 
and I will make draft on you for the balance, from time 
to time. Yours truly, 

John Scott, M.D., 
Superintendent. 



I left home, it seems a year. You ask me how I like 
this place. I cannot say that I like It very much, it Is 
almost like being in prison. You have to get up early, 
go out of doors in all sorts of weather, eat all kinds of 
horrid things— and you must eat them, too, and then you 
have to go to bed early, just as you begin to enjoy your- 
self. They make you sleep with all the windows open, 
and they do not let me have a feather bed. You know 
how I hate hard beds, and cold of any kind. My cough 
is better, but I will never believe that there was anything 
wrong with me. Doctor Scott is very kind, but I am 
very homesick. Your loving daughter, 

Mary. 



(5) St. Ethelreda's Ho.spital, N. Y. 

Dear Doctor Lee :— Dr. Scott writes me that your 
daughter has improved in a marked degree since she 
came under his treatment. She has gained nearly eight 
pounds, her temperature has fallen considerably, and she 
is in every way better. I notice that she is somewhat 
impatient of restraint, and does not like the compulsory 
out-of-door life. You must use your influence with her 
to tolerate these things. They are done for her good, 
and if she perseveres in following Dr. Scott's treatment 
she will be practically cured by the first of next June — 
barring accidents. Yours very sincerely, 

Alfred McGee. 



(4) The Sanatorium, Maine. 

My Df.ar Mother : — I received your letter yester- 
day, and though it was only a fortnight yesterday since 



(6) Chicago. 

Dear Madam : — A mutual friend of ours has in- 
formed me that your daughter is an inmate of the 
Sanatorium, Maine. 

You will see by my letterhead that I have made a 
specialty of tuberculous cases for over 30 years, that I 
have invented the only reliable cure for that disease 
known to the world, and, by reference to almost any 
paper, you will see that I am spending thousands of 
dollars every year in advertising the fact to the people of 
the United States and Canada. 

You are no doubt aware that the physician who sends 
a patient to one of these socalled sanatoriums receives 
a bonus from the proprietor in every case. This accounts 
for the extortionate charges for board, treatment, and 
medicine. My correspondent informs me that you are 
paying $8 a week for your daughter's board alone ; of 
that sum a quarter, or possibly a third, goes to the 
doctor who sent her there, as his commission. 

For |10 a month, or possibly less, I can furnish her 
with the treatment that has cured hundreds of people — 
Senators, Congressmen, bishops, ladies who are promi- 
nent in the Women's Christian Temperance Union, 
actresses, for the sun shines on the j ust and the unj ust alike 
— and it is my duty to cure all the sick who appeal to 
me, irrespective of their profession. I enclose copies of 
testimonials, and I hereby agree to forfeit $1,000 for each 
and every one which is not genuine. If she decides to 
take my treatment she will be under j'our own supervis- 
ion, free from the irritating restraint so often imposed on 
the inmates of " sanatoriums ; " her diet will be practi- 
cally unrestricted, and she will enjoy the advantages of 
home life combined with the best medical advice (free of 
charge) and the best medical treatment the world can 
afford her. 

I have no desire to foist my services upon you, but I 
think it is my duty to inform you of my ability to cure 
tuberculosis. 

Trusting that you will pardon the liberty I have 
taken, Yours for health, 

Andrew A. Scooper, M.D., 
President Scooper Medical Institute, Chicago, 111., 
U. S. A. 



64 



American MedicinbI 



CORRESPONDENCE 



rjANCARY IS, 1906 
LVOL. XI. No. 2 



(7) St. John's Rkctoky, Mokrhuopolis. 

Dear Alfred: — I deeply regret to say that Mrs. 
Lee has decided to remove Mary from Dr. Scott's sana- 
torium. I have said all I could to prevent it, but in 
vain. The child — for she is nothing else — is very impa- 
tient of restraint. She imagines she is perfectly cured, 
and her mother says she will derive no benefit from a 
prolonged stay in an institution she detests. 

I could have kept her there for a year, thanks to you, 
for the most reasonable terms you procured for her, but 
she and her mother are against me, and I cannot with- 
stand them both. I regret to say that my wife has no 
confidence in Dr. Saunders — I regard him as an espe- 
cially able man for a country practitioner. 

She has been corresponding with a Dr. Scooper, of 
Chicago, who claims to beaspecialist on tuberculosis. Do 
you know him? Perhaps you have met him, as you 
are both interested in the same subject. 

With very, very many thanks for your kindness, 
Your very sincere friend, 

John Lee. 



(8) EXTRACT FROM A REPLY TO THE FOREGOING. 

" I do not knowDr. Scooper, nor have I any wish to 
see him, unless the 'State of Illinois sees fit to install a 
public pillory, and place him, and some dozens more 
like him, therein. Your own sense will convince you of 
the fact that it is impossible for anyone resident at a 
distance of two thousand miles from the patient to treat 
any case of tuberculosis." 



(9) St. John's Rectory, Mokrhuopolis. 

Dear Dr. Scooper :— My daughter has finished, or 
nearly finished, the course of treatment you sent her 
three weeks ago. She seems very bright and cheerful, 
her appetite is fair, and her color has come back. She 
has lost in weight slightly, but she attributes this to her 
having discarded her heavy winter clothes. Enclosed 
please find postal order for $10, for which please send me 
another course of treatment. Kindly address it to Mrs. 
Hill, Milliner, Main street, Morrhuopolis, as I regret to 
say that Dr. Lee is not in favor of your treatment. 

Yours truly, 

Catherine Lee. 



(10) Chicago. 

Dear Madam : — I am in receipt of your letter of 
the fith inst. and in reply, I am sending another course 
of treatment. By reference to ray books, I find that 
this is the sixth. The slight hemorrhage you mention 
should not occasion you any alarm ; it is merely nature's 
way of disposing of superfiuous blood. Sixty or seventy 
years ago the doctor in attendance on your daughter's 
case would have accomplished this with the aid of a 
lancet ; I leave nature to do its work. 

At the same time, I desire to draw your attention to 
my " Hajmofactor " or blood-maker. I enclose a de- 
scriptive pamphlet, and you will notice that it promotes 
the secretion of new, rich blood, by passing a gentle 
electric current through the heart, liver, kidneys, and 
lungs. It is worn under the clothing, and does its work 
day and night. It occasions no pain, other than a slight 
tingling at the first contact of the electrodes with the 
flesh, and it generates enough electricity to run two 
64-candle-power incandescent lights. I make a special 
discount on this apparatus to the clergy, which reduces 
the cost to $50, expressage paid. May I send you one? 
With regard to the night-sweats, double the dose of 
vitaline and give six instead of four capsules of bovisang 
per day. 

Anticipating that you will follow these directions, I 
have doubled the quantity of these medicines. You can 
remit the additional cost ($7.50) when you next write 
me. Yours for health, 

Andrew A. Scoopeb, M.D. 



(11) St. John's Rectory, Morrhuopolis. 

Dear Doctor Scooper : — In reply to your kind 
letter, I am glad to say that I am improving every day ; 
I still feel somewhat weak, and last week I lost a little 
blood, but I feel confident that when the warm weather 
comes again I shall be perfectly cured. I am wearing 
the hjemofactor all the time, and every day I take ten 
capsules of the bovisang. Mother wishes you to send on 
two bottles of vitaline and four boxes of the capsules. 
I enclose postal order for the amount. I am sending 
my photograph as requested ; it was taken over a year 
ago. With many thanks for the good you have done 



me. 



Yours very sincerely, 

Mary Lee. 



(12) St. John's Rectory, Morrhuopolis. 

My Dear Alfred :— I write to inform you that our 
dear Mary passed away yesterday. I am thankful to 
say that the end was swift, and she was spared much 
sufftering. I induced her to see Dr. Saunders about a 
month ago, and he told me there was absolutely no 
hope. He advised me to humor her in any way I could, 
and I obeyed his instructions. Until the time of her 
death she firmly believed she was on the road to com- 
plete recovery. She even wrote that fellow— Scooper, 
in Chicago — that she was almost cured. He must have 
received her letter within a day or two of her death. 
You know how averse I was to removing her from 
the sanatorium, but it was impossible for me to with- 
stand the united appeal of herself and my wife. 

We have paid this Dr. Scooper about $300 for his 
medicine and treatment. I would have gladly paid ten 
times the sum if it had done her any good. I am firmly 
convinced that, had she seen fit to follow your instruc- 
tions and complete her course at the sanatorium, she 
would have been alive at the present day. 

Again thanking you for your kindness to my poor 
girl, Your very sincere friend, 

John Lee. 



(13) Chicago. 

Dear Madam :— I very much regret to hear of the 
death of your daughter, more especially as she wrote 
me a most bright and cheerful note only a few days ago. 
While I meet with an occasional case I am unable to 
cure, it is almost invariably one where someone else has 
attended it in its early stages. 

I note your remarks about the medicine which 
arrived too late to be of service to you, and I would 
gladly take it back and refund you the money, but to do 
so would be a breach of my business regulations. I would 
recommend you to keep it by you, and when any of 
your friends are threatened with lung trouble you can, 
no doubt, dispose of it to them. Yours for health, 
Andrew A. Scooper, M.D. 



(Clipped from the Skoichegan Democrat, three years 
later.) 

"The portrait printed above is that of Miss Mary 
Lee, the only daughter of a prominent doctor of divinity ; 
she narrates below the great benefit she derived from 
the celebrated Doctor Scooper's treatment." Here fol- 
lows letter No. 11, and half a column of advertising, 
disguised as reading matter. 



(From the same issue of the Democrat.) 

" The colored boy. Bill Harris, who was remanded by 
Judge Mill, yesterday, on a charge of obtaining fifty 
cent« under false pretenses was brought up for sentence 
this morning. His Honor said that as it was a first 
offense, he would .be lenient, and sentenced him to six 
weeks in jail, with hard labor." 



January IS, 1906T 
Vol.. XI, No. 2 J 



SEXUAL PHYSIOLOGY AND HYGIENE 



fAMERICAN MEDICINB 55 



ORIGINAL ARTICLES 



SHOULD THE YOUTH OF THIS COUNTRY BE IN- 
STRUCTED IN A KNOWLEDGE OF SEXUAL 
PHYSIOLOGY AND HYGIENE ? 

BY 

PRINCE A. MORROW, M.D., 
of New York City. 

Universal elementary instruction has come to be 
accepted as the most valuable of all means for the pre- 
vention of communicable diseases. Its importance is 
emphasized in the case of diseases, the communication of 
which lies entirely within the control of the individual. 

Since the special class of disea.ses, which it is the 
object of this society to prevent, have their almost exclu- 
sive origin in the irregular exercise of the sex function, 
it would seem logical to conclude that a knowledge of 
the physiology and hygiene of this function would con- 
stitute a valuable prophylactic measure. 

The question assigned me in this discussion is, Shall 
the youth of this country receive this instruction? In 
the necessarily brief limits of this paper, I shall consider 
it chiefly from the standpoint of its practical utility. 

In his exhaustive treatise on "Adolescence," W. 
Stanley Hall, president of Clark University, declares 
that the physiology of sex " is the largest and most com- 
plex, the most important and interesting of all human 
themes." Further, that "this age and theme is the 
supreme opening for the highest pedagogy to do its best 
and most transforming work," etc. 

The education contemplated in our program is, how- 
ever, comparatively restricted in its scope. It is simply 
to give to the youth of this country a clear comprehen- 
sion of certain physiologic truths which have a direct 
bearing upon the regulation of their sexual lives and of 
the serious consequences, in the shape of disease and 
death, which follow a breach of hygienic laws. la other 
words, it is to teach them how to live according to the 
laws of a healthy nature. It is obvious, however, that 
they cannot be expected to so live unless they know 
what those laws are. 

Herbert Spencer, in his masterly essay on " Educa- 
tion," defines what knowledge is of most worth in the 
order of its importance as follows : Of primary impor- 
tance is that knowledge relating to self-preservation, or 
which ministers directly or indirectly to the maintenance 
of life. Next in importance is that knowledge relating 
to self-perpetuation or parentage, which prepares for the 
creation and rearing of offspring. Of subordinate im- 
portance is the knowledge which prepares for the main- 
tenance of proper social and political relations, as well 
as the gratification of the tastes and feelings. " Strangely 
enough," he says, " the most glaring defect in our pro- 
grams of education is entirely overlooked. To prepare 
the young for the duties of life, is admitted by all to be 
the end which parents and schoolmasters should have in 
view. Though some care is taken to fit the youth of 
both sexes for society and citizenship, no care whatever 
is taken to fit them for the .still more important position 
they will have to fill — the position of parents." 



The education proposed by this society has a three- 
fold application. It ministers : 1. To self-preservation, 
in the prevention of diseases which may seriously com- 
promise the health or life of the individual. 2. To self- 
perpetuation, as it specifically relates to the preservation 
of the integrity of the function through which life is 
perpetuated. 3. To the social organization, as it is only 
by keeping the springs of heredity pure and uncontam- 
inated that the future fathers and mothers can discharge 
their highest duty to the State in the production of 
healthy and capable descendants. 

Since health is the essential condition of the fullest 
and most complete living, every one, perhaps, would 
endorse the abstract proposition that a knowledge of the 
functions of the human body and of those physiologic 
laws, which have a direct bearing upon the preservation 
of health, is of superior importance, and should form 
part of a rational education, but insofar as this knowl- 
edge relates to the laws of life and reproduction, it is not 
recognized as a desideratum. On the contrary, it is con- 
demned, both by sentiment and established routine, as 
unfit and improper. 

The maxim, "Know Thyself," is regarded as the 
concrete expression of the highest wisdom, but our edu- 
cational policy is entirely to ignore sex — that most 
important part of self— as if it were practically nonex- 
istent, and yet we must recognize that the development 
of the sex function is intimately associated with the 
physical, mental, and moral growth ; it profoundly 
modifies the intelligence, habits, and character ; it is 
bound to be a factor, and a most important factor, in the 
future life and conduct of the individual. It is prac- 
tically certain that this function will be exercised nor- 
mally or abnormally, legitimately or illegitimately, by 
9 out of 10 of the rising generation, and with results 
beneficial or harmful — it may be disastrous to themselves 
and to others. Experience shows that thousands suffer 
physical and moral wreckage from trusting to blind in- 
stinct as the sole and sutRcient guide for its regulation. 

It would seem to be the aim of most parents to launch 
their children into the world in a state of Edenic inno- 
cence, and there is nothing more fatuous than their illu- 
sion that they succeed. 

The principal of a large preparatory school in this 
city said to rae the other day : " This morning a gentle- 
man entered his son, a well-grown lad of 17, in my 
school. He was most particular in his inquiries whether 
there were any bad boys in the school. ' My son,' he 
said, 'is a.s innocent as a babe, and his mother and I 
wish to keep him so.' " This is the ideal of many 
parents who confound innocence with ignorance. " The 
error is noble, the vanity fine," but it is not possible, 
even were it desirable, to preserve this state of infantile 
ignorance. It is natural that the youth .should wish to 
know something of the origin of life— whence he came 
into the world, and how human beings are propagated. 
The " fable of the stork " scarcely survives the "myth of 
Santa Glaus." In seeking this knowledge the youth is 
but obeying a law of his mental evolution. 

The consciousness of sex is the first mark of adoles- 
cence. It is inconceivable that a sentient, intelligent 
being should be conscious of the stirrings of new sensa- 



66 A^MEKICAN MEDIOISKI 



SEXUAL PHYSIOLOGY AND HYGIENE 



[JAN0AKY 13, 1906 
Vol. XI, No. 2 



tions and impulses which center in the sex organs with- 
out wishing to know something of this physical endow- 
ment. The mind of youth is peculiarly avid of this 
knowledge, especially since the development of sex 
comes at a period when interest and curiosity are the 
dominant intellectual traits. The very mystery and 
concealment thrown around .sex supply the strongest 
incentive to this curiosity, and since this knowledge can- 
not be had from legitimate sources — that is, from parents 
and instructors — it is gained surreptitiously, and usually 
from depraved sources — from dis.solute companions or 
from erotic or quackish literature. 

After all it is not a question whether the youth shall 
learn something of sex and self, rather it is a question 
whether it shall be scientific truth or dangerous error, 
whether this instruction shall be sound, sanative, whole- 
some, and moralizing in its influence, or whether it 
shall be false, unhygienic and demoralizing in its ten- 
dency. 

Now as to its practical utility. One incidental, but 
most important benefit from the teaching of sexual phys- 
iology, if sufficiently timely, would be the prevention 
or correction of that physical sin known as self-abuse, 
the extensive prevalence of which among youth need 
only be mentioned. While the consequences of the un- 
natural exercise of the sex function forms no part of this 
society's study, I may be permitted to allude to it 
briefly, in passing, as it constitutes in my opinion an 
important etiologic factor in the initiation of sexual 
debauch. I am aware that it is popularly supposed that 
self-abuse and sexual intercourse are antagonistic — by 
many, the one is regarded as the necessary alternative of 
the other. So far from being a protective the former is 
a most powerful provocative of the latter. According to 
my observation it is not the strongly sexed, the most 
virile young men who are most given to licentiousness, 
but those whose organs have been rendered weak and 
irritable from this unnatural exercise — in whom the 
habit of sensual indulgence has been set up and in whom 
self-control has not been developed by exercise. These 
sexual weaklings yield to sensual impulses which the 
normally strong feel, but repress. Many a young man 
enmeshed in the toils of this solitary habit seeks in 
licentious intercourse an eScape; too often physicians 
recommend the latter as a means of cure. This practice is 
mentioned only to be condemned. " Get a woman " as a 
therapeutic formula, is as unhygienic as it is immoral. 

Perhaps the strongest argument for instruction in sex- 
ual physiology is that it would correct the conventional 
view, based upon a perversion of physiologic truth, that 
incontinence in men is a necessary condition of health.' 
Sound physiologic teaching would demolish this strong- 
hold of masculine licentiousness — the socalled " sexual 
necessity " — behind which is entrenched the double 
standard of morality. Physiology gives the lie to the 
"wild oats'' Action ; it refutes that wretched sophistry 
which would strip masculine immorality of its guilt and 
make of it a pardonable pastime — even a hygienic pro- 
cedure. Physiology clearly teaches what is confirmed 
by experience, that continence is compatible with the 
highest physical and mental vigor. .A.s Sir James Paget 
has said, no man was ever the better for incontinence or 



the worse for continence. Licentiousness finds no justifi- 
cation or shadow of support in the teachings of sexual 
physiology and hygiene. 

So much for the constructive phase of this education, 
which aims to build up what may be termed the " sex- 
ual character" of the individual upon the foundations of 
sound knowledge, self-reverence, respect for women and 
for good morals. 

There is, however, another phase of this hygienic 
education which has perhaps a more important bearing 
upon the specific object of this society's work — the pre- 
vention of venereal diseases. 

It is generally recognized that these diseases have 
their chief source in that irregular commerce between 
the sexes known as prostitution, and that exposure and 
the contraction of disease are almost in.separable. It is 
the province of hygiene to warn against the exercise of 
any function of the body under conditions which cause 
disease, and in order that this warning may prove 
effective as a restraint, it is necessary that those who 
expose themselves should know to ivhat they expose 
themselves. An adequate conception of the real signifi- . 
cance and veritable danger of these infections forms, 
then, an essential part of this hygienic education. 

Many parents who might look with favor upon 
instruction in sexual physiology, would draw the line at 
the mention of sexual disease. Such education, it is 
alleged, would open up a horizon of shameful and repul- 
sive morbidity which had best be hidden. From the 
scientific standpoint, these infections are merely matters 
of microbic invasion, and the shame, if there be any, 
attaches to the act of exposure and not to its pathologic 
consequence. But, after all, the young are not so igno- 
rant of the existence of the diseases incident to vice as 
their elders pretend to believe. Many of them have a 
theoretic, and some of them, unfortunately, a practical 
knowledge while yet in their early teens. 

Fournier's statistics show that of every 100 syphilitic 
infections among the educated, well-to-do classes, no 
fewer than eight occur from the fourteenth to the nine- 
teenth year ; in the working classes this proportion rises 
to 13^. Of every 100 cases of gonococcus infection, 12 
occurred from the thirteenth to the nineteenth year. So 
that it may be accepted as a low conservative estimate 
that 10^ of all venereal infections occur before the nine- 
teenth year, or during the scholastic age. From the 
nineteenth to the twenty-third year there is a rapidly 
ascending scale of frequency. Youth and early man- 
hood represent, then, the period of greatest sexual 
vulnerability. 

There is no reason to believe that the precocity of 
vice is less marked in this country than in France. 
Physicians can testify to the great frequency of juvenile 
contaminations in this city and what has been termed 
"the amazing and unparalleled existence of vice" in 
student life has been recently publicly commented upon 
by teachers in colleges and universities. 

While it is difficult to formulate the precise period at 
which this pathologic lesson should be given, it is hardly 
probable that it will be premature. It has been claimed 
that up to the age of 14, the youth should be protected 
against himself, after that against outside temptations. 



January 13, 1906T 
Vol. XI, No. 2 J 



MEDICAL TREATMENT OF ABDOMINAL PAIN 



[American Medicine 57 



The objection that this early education would pre- 
cipitate the evil we wish to prevent is hardly worth re- 
futing. No young man was ever led into licentiousness 
by reading a serious book upon its dangers. It would 
be just as insensate to claim that he would be tempted to 
drink more freely from an infected water-supply when 
told that it contained germs of typhoid. 

The importance of this prophylactic education to the 
rising generation is enhanced by the fact that the inci- 
dence of these diseases falls most heavily in early man- 
hood, at or before the marriageable age. These infec- 
tions are not limited to those who contract them in 
licentious relations, but they are introduced into legit- 
imate unions, they condemn thoasands of innocent wives 
to sterility, to lifelong invalidism, or mutilation to save 
their lives ; they are transmitted in full virulence to 
their offspring, peopling our asylums with the blind, the 
idiot, the feeble-minded and phj'sical degenerates, they 
thus constitute a social peril of the greatest magnitude. 

From this incomplete survey of the subject it would 
appear that the education contemplated in our program 
is designed to have an important influence not only upon 
the individual life, but upon the social organization. It 
may be fairly claimed that education in sexual phys- 
iology and hygiene conduces to health and physical 
morality by inculcating the ideal of a clean mind in a 
sound body, and by teaching that the reproductive func- 
tion is given for a higher purpose than mere sensual 
gratification— that it should be restrained by reason, 
regulated by seU-control, and exercised in the legitimate 
way imposed by marriage. I hold it to be a cardinal sin 
against youth to deny them that knowledge which 
would safeguard them against ignorant exposure to 
dangerous infections, the existence of which many of 
them do not realize and the significance of which none 
of them fully comprehends. 

This education, to be salutary as a safeguard, should 
be given in youth, for it is at this period that the founda- 
tions of the sexual character are laid and habits of mind 
and practices are formed, which, in a great measure, de- 
t(!rmine the future sexual life of the individual. 



THE MEDICAL TREATMENT OF ABDOMINAL PAIN 
NOT OF GASTRIC ORIGIN.' 

BY 

JAMES E. TALLEY, M.D., 
of Philadelphia. 

Since pain in the abdomen is usually but the surface 
|ldication of various pathologic conditions that exist in 
lie different underlying organs, nowhere than here is it 
jore true that he who diagnoses well cures well. Per- 
fips nowhere else is an absolutely accurate differential 
agnosis more difficult than in the upper quadrant-s of 
lie abdomen, the lower having the advantage of the 
ftginal and rectal exploratory routes. A careful diag- 
losis being presupposed, we pass to the treatment, draw- 
ing largely for our classification of the causes of abdomi- 
nal pain upon the article of Musser in the " Transactions 
of the Medical .Society of the State of New York, 1904." 

' Prepared for the West Philadelphia Branch of the County 
Medical Society, February 11, 1905. 



I. Hernias. — Hernias of the linea alba (epigastric), 
the linea semilunaris, as well as small hernias of the 
ordinary varieties, are frequently the cause of abdominal 
pain. The relatively large number of epigastric hernias 
seen in the various gastrointestinal clinics on the con- 
tinent, is due perhaps less to racial peculiarities than to 
the fact that there are collected in larger numbers all 
sorts of the various ptoses with the concomitant relaxa- 
tion of the abdominal walls which favor hernial devel- 
opment. 

In this connection may be mentioned also the article 
by Stockton,' " Abdominal Pain from Unsuspected Irri- 
tation at the Internal Hernial Ring." In dispensary 
practice I have seen two cases of the latter, one in a 
horseshoer, and one in a man who used all day long a 
foot-lathe ; both of these were relieved by properly fitting 
trusses. In this class of cases, as well as in painful 
hernia of the ordinary varieties, a truss is usually suffi- 
cient. A large proportion of the epigastric hernias gives 
no inconvenience, but when they are the source of dis- 
tress a truss or a pad with adhesive plaster may be tried. 
However, according to von Bergmann, operation offers 
the only sure method of relief and cure. 

II. Functional Neuroses. — We all agree with Musser 
that the more accurate our diagnoses, the less abdominal 
pain due to hysteria we shall see. One needs to keep 
constantly in mind that neurotic patients are no less 
subject to genuine morbid processes than others, and we 
should not let the too evident neurosis blind us to the 
anatomic changes that can be found by care and patience. 

A nervous young woman accustomed to appear on the 
public platform was for years frequently incapacitated 
by severe attacks of epigastric pain brought on by the 
excitement attending her work. The neurosis was the 
most evident thing, the attacks not characteristic ; she 
had gone through a rest cure, a course of tamponage and 
electricity, lavage and dieting, and yet grew more 
nervous and lost weight until finally an attack seemed 
to point more toward gallstones. An exploratory oper- 
ation was done, some half dozen large gallstones 
removed, and now after some two or three years of free- 
dom from attacks she has gained wonderfully in weight 
and is perfectly well. 

A girl of 13 whose own mentality as well as that of 
her family was such as to be utterly useless in giving an 
account of her troubles, kept the whole family up several 
nights crying out that she had a clutching in her left 
side at the edge of the ribs " which choked off her 
wind." Repeated examinations on successive days 
revealed no tenderness, nor any trouble. Finally she 
was admitted to the hospital for observation, and during 
several days' stay she had several hysteria-like crying 
spells, but that was all. A few days after discharge she 
returned with a copious eruption of herpes zoster, after 
which she had no more attacks. 

The treatment suggests itself when once the diagnosis 
is made. 

III. Intoxicatimis. — Musser has called attention to ab- 
dominal pain as a precursor of uremia, the treatment of 
which is, of course, the treatment for the uremia. 

In lead intoxication the occupation and the blue line 
on the gums are the special diagnostic points. In lead 
colic, magnesium .sulfate and sodium sulfate serve the 
twofold purpose of opening the bowels and acting as an 
antidote. The spasms of the intestine may be relieved 

' American Medicine, June, 1904. 



58 AMERICAN MEDICINE] MEDICAL TREATMENT OF ABDOMINAL PAIN 



rjANnAKY IS, 1906 

LVOL. XI, No. 2 



by large hot enemas, by atropin hypodermically, and 
perhaps eserin also a little later to promote peristalsis. 
Usually the pain is so intense in well-developed eases 
that morphin hypodermically is a necessity, though, 
of course, the less we use, the less it will interfere with 
the desired activity of the bowels. The after-treatment 
consists in the prevention of further ingestion of lead 
and promotion of its elimination by potasssium iodid 
and pilocarpin internally and potassium sulfid baths. 

Under this head may be mentioned a rather unique 
case seen some dozen years ago. 

A masseur at the Orthopedic Hospital was seized 
with pain in the right iliac fossa ; aside from this a tem- 
perature of 100° and urine loaded with urates and uric 
acid crystals were the only symptoms. The diagnosis 
appeared to lie between catarrhal appendicitis and 
gravel, without being distinctive of either. The resi- 
dent was asked to count the leukocytes and he found 
plasmodiums in abundance. The exhibition of quinin 
was followed by relief and though I have seen him 
occasionally during the intervening years, he has never 
had any recurrence of symptoms pointing to appendicitis 
or gravel. 

A suflacient explanation of the connection between 
the malarial infection and the iliac pain does not occur 
to me. 

IV. Abdominal Pain Not Due to Disease below the 
Diaphragm.— YLe who examines his patients systematic- 
ally is unlikely to take the crisis of locomotor ataxia for 
genuine abdominal lesions, and yet Billings mentions 
cases that were referred to him for supposed gastric dis- 
ease. Last year I saw a man of 48, who had only 
Argyll- Robertson pupils and severe attacks of epigastric 
pain. The possibility of there being gastric crises was 
finally set aside by a characteristic attack of gallstone 
colic followed by a moderate icterus. 

Not infrequently the first symptom of thoracic aneu- 
rysm is intercostal neuralgia which may radiate to the 
abdomen. 

As to diaphragmatic pleurisy, I have seen an elderly 
woman succumb, absolutely worn out by the pain, in 
spite of the united resources of three consultants of note. 
Though abdominal pain is more common in the 
pneumonias of children, adults are not exempt. A 
central pneumonia in a woman of 40, with intense pain 
in the right iliac fossa, and vomiting, kept her attend- 
ants on the anxious bench for two days before a diagno- 
sis could be made without reserve. 

A case of persistent pain under the left edge of the 
ribs was explained only when the to-and-fro friction rub 
of chronic pleurisy near the left base was discovered. 

V. Hepatic. — The possible hepatic conditions are 
perihepatitis, gallstones, cholecystitis, and cholangitis. 
Of these, cholelithiasis, with or without cholecystitis, 
holds first place as a cause of acute abdominal pain. 

Biliary Colic— A few whitfs of chloroform will ease 
the excruciating pain until the hypodermic of morphin 
has had time to act. The pain is usually so severe as to 
require morphin, and physiologically, atropin sulfate 
and nitroglycerin should add to the effect of the 
morphin. Drinking hot water, the local application of 
large hot compresses over the liver region, and perhaps 
the full hot bath may all be helpful. If the stomach is 



retentive, the saline cholagogs should be given to un- 
load the bowels and for the depleting effect. 

Treatment between the ^Waefe.— The indications for 
the radical surgical treatment Ur. Deaver will cover. 
The next 20 years will do much both within and with- 
out the profession toward a better understanding of the 
necessity for early radical treatment. For the present 
there remains for the internist, patients who have had 
but one or two mild attacks and by far a too large per- 
centage who have had severe attacks and yet refuse 
operation, so long as there are no secondary complica- 
tions. Also, in our lists of gallstone ca.ses we all have 
some patients who have reached their threescore years 
or threescore and ten, the condition of whose kidneys 
and hearts, in the absence of impelling indications for 
operation, make us wary of insistence. For all these 
there are at least palliative if not curative resources. 
That any known medicinal agent can dissolve actually 
existing gallstones in the gallbladder is a fallacy. 
Brockbank has proved that the saline laxatives (chol- 
agogs) have no such effect. He allowed gallstones to 
remain for two weeks in 10^ solutions of the following 
sodium salts: Salicylate, sulfate, benzoate, phosphate, 
bicarbonate, chlorid, as well as potassium sulfate and 
ammonium chlorid, and at the end of that time the 
stones showed no loss in weight. 

The experiments with olive oil, oleic acid, and 
animal soaps in the laboratory are more satisfactory, as 
they cause the stones to soften and disintegrate. But 
gallstones in the laboratory and in the gallbladder are 
under different circumstances. There is no evidence to 
prove that even when given in large amounts, enough 
oil or its fatty acids or soaps is absorbed to have any 
solvent effect on the existing gallstones. However, since 
the products of digested fat do occur in the bile and dis- 
solve cholesterin, there is a possibility that the giving of 
olive oil may help prevent the formation of more stones, 
and it is still given by some in amounts of 2 oz. to 10 oz. 
daily by mouth or rectum. 

Though the salines do not actually dissolve gallstones, 
the experiences at Carlsbad alone prove that the waters 
have a very decided and beneficial effect. Their action 
probably depends upon the fact that they render the bile 
more fluid and thus prevent further formation of stones, 
cleanse the gastric, duodenal, and perhaps even the 
biliary mucous membrane, and increase peristalsis, which 
not only keeps the bowels free, but depletes any existing 
irritation or inflammation within or without the gall- 
bladder. No one claims any longer that the Carlsbad 
water has any specific action, so the patient will prob- 
ably do as well if he drinks freely every morning of our 
own Saratoga or Carlsbad, or the Bedford magnesia 
water, or even large quantities of plain hot water con- 
taining 1 dr. or 2 dr. of sodium phosphate or sodium 
sulfate or magnesium sulfate. 

Of all the drugs suggested, perhaps sodium salicylate 
and sodium benzoate, because they are bile stimulants, 
are at least as useful as any. They may be given, 
according to Chauffard's' suggestion, 1 gm. to 2 gm. 
(15 gr. to 30 gr.) of each, daily for 10 to 20 days each 



' Progressive Medicine, December, 1903. 



January is, 1906T 
Vol. XI, No. 2 J 



MEDICAL TREATMENT OF ABDOMINAL PAIN 



[AUKBICifn' Medioins 59 



month and continue for months. In this connection 
may be mentioned that Kuhn (quoted by Steele') has 
found salicylic acid and sodium salicylate the most effi- 
cient biliary antiseptics. They are freely secreted in the 
bile and his experiments have shown that they have a 
very decided germicidal action in very small percentages. 

Though ether, chloroform, turpentine, and a host of 
other remedies have been used and find their champions, 
they are, to say the least, not superior to the salicylates. 

Hygiene. — Siace women furnish the larger percentage 
of gallstone jjatients, attention to lacing is important. 
The general stasis produced by the constriction of corsets 
affects not only the circulation but also the flow of bile 
itself, a fact which every autopsy room sees proved by 
the actual indentations and malformations of many 
female livers. Want of sufficient exercise with its 
attending constipation is an element not to be over- 
looked. 

J>te<.— Excessive use of meats and starches and alco- 
hol must be forbidden. Sufficient albuminous food 
must be taken, as the metabolism of albumin furnishes 
the sodium glycocholate and taurocholate of the bile, 
which are the solvents of the cholesterin. Insufficiency 
of these bile salts allows precipitation of cholesterin and 
gallstone formation. Butter and other animal fats are 
allowable, since fats seem to have some favorable effects. 

V. Renal Pain : Nephrolithiasis : Floating Kidney : 
Intermittent Hydronephrosis : Pyelitis. 

Nephrolithiasis. — The treatment naturally falls under 
two heads — that of the renal colic and of the condition 
during the intervals. The relaxation sought in renal 
colic may be procured by a hot bath, by hot local appli- 
cations (poultices or stupes), by inversion or other 
change in position, by chloroform, and finally by 
morphin, with atropin or nitroglycerin. The pain is 
often so intense and persistent that more than one hypo- 
dermic may be necessary to secure relief. 

The treatment during the interval consists in atten- 
tion to quiet living, to avoiding sudden and heavy exer- 
tion, and yet taking enough gentle exercise to promote 
digestion and elimination, especially if the occupation 
is sedentary. The diet should be antilithemie. Espe- 
cially should wines and malt liquors be banished. But 
if the patient must have alcohol, good whisky, well 
diluted, should be allowed. 

If the urine is very acid, the patient should drink 
large quantities of pure water, as Poland, containing 
potassium bicarbonate or potassium citrate, in 1 gm. to 
1.3 gm. (15 gr. to 20 gr.) doses three or four times a day, 
or, if preferred, genuine lithia or vichy celestin. The 
continuation of these potassium salts in 2 gm. to 4 gm. 
(J dr. to 1 dr.) doses three or four times a day, is 
known as Roberts' solvent treatment (of stone), but that 
it can have any genuine .solvent action, appears rather 
unlikely. The same may be said of piperazln in the 
ordinary doses given, and yet it serves so well to clear 
the continuous lateritious deposit from the urine of 
gouty individuals that one feels loath to award it no 
place. 

If the urine is alkaline, lithia and vichy are contra- 

' Progressive Medicine, December, 1904, 



indicated, but plenty of pure water with urotropin, 
formin, elixir of uritoneor sodium benzoateor ammonia 
will render the urine acid and keep it aseptic. 

Among the resorts patronized in this country by 
such patients are Saratoga, Bedford, Poland, and Cam- 
bridge Springs. 

If the pain is continuous or attacks repeated at very 
short intervals or there is any evidence of actual stone 
as shown by the skiagrams, or the urine shows signs of 
pelvic and perhaps even renal irritation, then the case 
becomes a surgical one. 

Movable Kidney. — The acute pain of this condition is 
the socalled Dietl's crisis, and the use of narcotics is 
necessary to procure relief. The chronic dragging dis- 
tress of a prolapsed kidney needs first of all the wearing 
of a properly fitted bamdage preferably adjusted while 
the patient is in the recumbent position. That the addi- 
tion of pads for either a ptosis of kidney or stomach 
affords any advantages I have not seen. If the patient 
is thin a course of treatment to increase the weight is to 
be considered, and tight lacing and severe exercise are 
to be tabooed. 

It strikes me as most excellent advice, if we discover 
a well-marked movable kidney and it is giving no par- 
ticular distress, to refrain from directing the patient's 
attention to the abnormality. At least two neurotic 
women would have had one less trouble to mend had 
not a painstaking masseuse drawn their attention to 
their displaced kidneys. 

Intermittent Hydronephrosis.— This trouble, though 
rare, if diagnosed, may need no treatment if mild. 
Perhaps a bandage may be necessary and if the tumor is 
large it becomes a surgical condition, as puncture alone 
relieves. 

Intestinal. — The sources of abdominal pain in the 
intestinal tract are almost innumerable. Strangulation, 
intussusception, volvulus, enteritis, whether of the 
acute, chronic or mucous variety, acute hemorrhage or 
perforation of ulcer, perversion of intestinal digestion 
and many other conditions may cause abdominal pain, 
but it is impossible to consider them in the time allotted 
me, and frequently the pain here is but part of a well- 
developed disease or condition the name of which carries 
the suggestion as to its treatment. 

The more recently discussed abdominal pain due to 
the mesenteric vessels sharing in the general atheroma 
should not be overlooked. The persistent use of vaso- 
dilators seemed to give relief in a recent case. 

Appendicitis is comparatively so frequent and of such 
importance that it merits more careful consideration. 

Appendicitis. — Though the discussions of the treat- 
ment of appendicitis are numerous, the general conclu- 
sions that a large percentage of the profession subscribe 
to are really few. That there is no specific medical 
treatment, that the condition is surgical, and that the 
surgeon should be called as soon as the diagnosis is sus- 
pected, few will gainsay. I have never seen nor heard 
of a patient operated on too soon. The diagnosis once 
reasonably sure, but few of us have missed at some time 
in our careers the heartache due to waiting for the inter- 
val that never came. 

However, between the diagnosis and the operation, 



60 Amebioan Mbdicine] 



CASE OF CEREBELLAR TUMOR 



rJANUARY 13, ISW 
LVOL. XI, No. 2 



or if permission is refused, or if there are contraindica- 
tions, there are certain well-defined things to do for the 
patient. 

Absolute rest in bed in the dorsal position with en- 
forced use of urine and bed pan are necessary. The 
withdrawal of all food and practically all liquid for 12 
to 24 hours prevents peristalsis and gives less material 
to ooze into the peritoneum in case the appendix does 
perforate. For thirst teaspoonful amounts of liquid or 
very small hot enemas will answer ; large enemas are . 
likely to promote peristalsis. P'or repeated vomiting, 
especially if there seems to be retained food, lavage has 
been advised. 

For the pain itself the use of the ice-bag is universal. 
It should be in place continually, with a layer of flannel 
or lint between it and the skin. Its size should be ample 
and the ice kept well replenished. If too heavy for the 
tender area a means of partial suspension must be devised. 
The Leiter coil is an alternative if the weight of the bag 
is really unbearable. A solution of menthol in alcohol 
has also been recommended. When children and nerv- 
ous individuals complain bitterly of the cold, we can 
find good authority for the use of hot applications. 

As in a large proportion of cases these local applica- 
tions fail to give the desired relief, the opium question 
arises. As very frequently the surgeon sees the patient 
once or perhaps twice between the suspicion of diagnosis 
and its final confirmation, the family practitioner has 
often to thresh out the subject with the patient and fam- 
ily, both of whom are beseeching relief, the one because 
of physical distress, the other from distress of mind due 
to the cries of the sufferer. In this emergency, patience, 
good judgment, and skill in handling people as well as 
drugs are requisite. The diagnosis once reasonably sure, 
the better alternative is to hurry up the time of opera- 
tion, but when this is impossible and the patient's 
lamentations are distressing to all concerned, the most 
decided opponents of the use of opium are not always 
entirely consistent in their writings and their actual 
practice. In such cases a single small dose of morphin 
by hypodermic if necessary, judiciously repeated once, 
gives the greatest relief and is harmless if the amount 
given is just enough to quiet the patient without affect- 
ing markedly the sensorium, the pupils, the amount of 
urine, and peristalsis. But comfort should not be pur- 
chased by an amount that obscures the symptoms, espe- 
cially when the diagnosis is uncertain. 

On the question of purgatives the opinion seems more 
uniform. The salines are relegated to the past as likely 
to be distinctly harmful by promoting peristalsis and 
possible perforation. Very early in the attack when 
there is a distinct history of the patient's having eaten 
indigestible food, divided doses of calomel are permis- 
sible, but not salines even here. 

Pancreas. — For acute pancreatic diseases causing ab- 
dominal pain there is no medical treatment. If they are 
diagnosed or suspected they should be watched with the 
surgeon from the start. 

Spleen. — That the spleen is not more often the seat of 
well-defined abdominal pain is remarkable when we con- 
sider how very frequently in postmortem examinations 
a perisplenitis is found. Infarcts are common and 



thrombosis and embolism of its vessels also occur. A 
case of splenic abscess reported by Gravitz simulated 
typhoid. These facts are, however, more important to 
the diagnostician than the therapeutist. 

Peritonitis. — For the pain of general peritonitis have 
been used locally mustard plasters, hot stupes, ice-water 
stupes, ice-V)ags, Leiter coils, and in strong individuals 
leeches. An amount of morphin hypodermically that 
gives a fair degree of comfort is indicated. To secure 
this, these patients require larger doses, but not the 
heroic doses of old. 

Purgatives are out of the question as long as there is 
the suspicion that the peritonitis arose from a perforated 
ulcer or appendix. A single enema to unload the bowels 
is permissible and small enemas containing suds and 
turpentine may be necessary to relieve the tympany. 

Pelvic. — Patients with salpingitis, ovaritis, metritis, 
and pelvic peritonitis need relief for the pain. Here 
large ice-bags or more usually large hot sand-bags are 
useful. Large hot douches add to the comfort as well as 
combat the inflammatory process. The depletion by not 
too drastric purgatives is beneficial. The promotion of 
peristalsis by eserin is desirable to prevent tympany, 
and an amount of morphin to secure quiescence alone 
demanded. 

Ectopic pregnancy must always be borne in mind as 
a possible cause of sudden abdominal pain. 



A CASE OF CEREBELLAR TUMOR.' 



BURTON CHANCE, M.D., 

of Philadelphia. 

Assistant Surgeon, Wills Eye Hospital; Ophthalmologist to German- 
town Dispensary and Hospital, Germautown. 

Before presenting this communication upon a rather 
unusual case of cerebellar tumor, I wish to state that the 
man in question was sent to me for ocular treatment by 
Dr. A. T. McMullin, of Kensington ; and I wish also to 
thank Dr. William Turner VanPelt for his care of the 
patient at the Episcopal Hospital during the la.st stages 
of his illness, and for his extreme courtesy in giving me 
the later history,, which thus enables me to present the 
case in full. 

The patient, a young man of 26, the fourth of eight 
children, had come from England in boyhood. He was 
a printer of cotton stuffs. He had passed through infancy 
and adolescence without serious illness. At about 15 he 
had an attack of insolation, from which he promptly 
recovered without sequels. His father died of heat 
stroke four years ago ; recently a paternal uncle died of 
apoplexy. There is no history of tuberculosis or of can- 
cer in the family. 

At Easter, 1904, the young man was suddenly seized 
with a violent attack of headache, which lasted four 
days. There were no unusual symptoms associated ; it 
caused no alarm, and good health was regained. In 
July he was married and sailed for England. In mid- 
ocean he felt very heavy-headed, so he remained in his 
berth until noon each day for the rest of the voyage. 
Once he was seized with violent vomiting. These 
symptoms were thought by the ship's surgeon to be only 
those of seasickness. After landing, and on arrival in 

' Read before the CoUeee of Physicians of Philadelphia, 
Wednesday, December 6, 1905. 



JANUABT 13, 1906T 
Vol. XI, No. 2 J 



CASE OF CEREBELLAR TUMOR 



{AmcBICSAM MKDICrNE 61 



London, he had severe headaches, and, without previous 
dyspeptic symptoms, violent attaclis of vomiting, which 
were projectile in character. Then for a considerable 
period thereafter, until about September, he had head- 
aches on alternate days, the attacks usually taking place 
on awaking in. the morning. He was not affected by 
sightseeing tours. After September, until sailing for 
home in October, there were infrequent attacks. On the 
voyage he was very sick, having but two well days ; on 
three of the days there were violent spells of vomiting. 
< )n landing, October 20, he vomited from 2 o'clock a.m. 
until 8 o'clock a.m. . 

It was at this time that his physician. Dr. McMullin, 
was sent for. The young man was suffering intensely 
from pains in the head, in the occipital and frontal 
regions. These pains were usually most violent early 
in the day, subsiding at evening. All of the bodily 
functions at this time were apparently normal, but later, 
about the middle of November, the right side of the face 
became crooked, which continued for about a week. 
The tongue was not affected. Now, for the iirst time, 
it was noticed that the external rectus muscle of the left 
eye was paralyzed, and a day or so later diplopia, 
which was said to have been alternating in character, 
set in. This was followed by dimness of vision, and 
photophobia. Except on the days of the headaches, 
when the arms and legs felt numb, he was able to exer- 
cise and to take long walks without fatigue. The head- 
aches had gradually subsided, and a loss in bodily weight 
was rapidly regained. At no time had his friends 
noticed alteration in his gait or carriage. He felt well 
and reasonably happy. At times, when he had his 
lieadaches, he became irritable when the younger mem- 
bers of his household were noisy. This is not to be 
wondered at, when we consider the fact that all of the 
family were members of an amateur orchestra. He had 
led a most pure life, and by his statement, he was free 
from venereal disease, yet he was greatly annoyed by a 
l)ainful priapism, which impelled him into inordinate 
sexual indulgence without gratification. 

The man was sent to me on December 22, 1904. He 
was five feet seven inches in height, robust, weighing 
about 14.") pounds, having a good, ruddy complexion. 
There was nothing remarkable in his gait or station. 
His movements about the darkened room were in the 
manner of one whose visual fields had been contracted. 
His expression was vacant, like the state of one having 
optic neuritis. The tendon reflexes were apparently 
undisturbed ; neither were disturbances of general sensa- 
tion complained of ; while objects and familiar utensils 
were handled with accustomed facility. His replies to 
my inquiries were clearly and concisely given, his 
memory being perfect and retentive. 

The chief complaints at this time were referred to the 
ocular apparatus. The visual acuity of the right eye 
was reduced to fi/15, of the left to 6/22.5 ; the accommoda- 
tion power was abolished, so that Snellen's reading types 
could not be read. The optic axes markedly converged ; 
the left external rectus muscle failed to effect parallelism. 
There was no nystagmus. Homonymous diplopia was 
amplained of, but it was not possible to measure it 
Itisfactorily. Except in outward rotation, the muscular 
aovements of the left eye were unlimited. The pupils 
leasured 4 mm. each, and were fixed, failing to respond 
the usual stimuli ; but when, however, the eyelids 
irere forcibly closed, and after pressure on the frontales 
luscles, the eyes suddenly exposed to strong light, 
lie pupils dilated widely. This paradoxic pupillary 
Jhenomenon was constantly obtained after repeated 
iperiments. When the facial muscles were at rest the 
fcormal relations of the two sides of the face were dis- 
irbed (the left side wa.s slightly drawn over to the 
Ight) ; when efforts were concentrated, the relationship 
etween the two sides became readjusted. The pro- 
truded tongue could be directed forward, though it was 
very tremulous. The visual fields were concentrically 



contracted ; colors were not perceived and the blind 
spots were greatly enlarged. There was no history of 
polyuria ; neither was albumin nor sugar detected. 

Ophthalmoscopic Examinaiion.—The right pupil was 
not perfectly round, nor was there a reflex during the 
examination with the mirror. Fine granular deposits, 
resembling those of ciliary exudation, were noticed on 
the anterior capsule. There were no signs of antecedent 
iritis. Projecting into the clear vitreous was a greatly 
swollen optic nerve head, the summit of which was 
measured by a plus 5 D lens. The retina was every- 
where edematous, the macular and foveal region re- 
maining like a deep pit surrounded by the raised retinal 
sheet. No areas of exudation were discovered. The 
arteries were constricted and reduced to threads, while 
the veins were great, broad, tortuous currents. On the 
swollen nerve head were several ilame-shaped hemor- 
rhagic extravasations. The fundus conditions of the left 
eye were quite similar to those noted in the right, 
though they were more extensive and pronounced. The 
hemorrhagic extravasations on the disc, as well as those 
in the liber layer of the retina, were larger and more 




numerous. These extravasations were like those seen 
in marked cases of hemorrhagic retinitis and other 
ocular diseases, and have frequently been noted in cases 
of cerebellar tumor. The intraocular symptom-com- 
plex differed, however, from that observed in the course 
of systemic disease. In the walls of the bloodvessels no 
signs of degeneration were apparent ; the entrance and 
exit of the currents were mechanically interfered with 
by the choked disc. 

In reviewing the history of the case, the points to be 
observed are: 1. Head pains localized at the occiput, 
though at times radiating to the vertex. 2. Vomiting, 
without nausea, nor dependent upon the ingestion of 
food; indeed, it invariably occurred in the morning. 

3. The early development of an intense optic neuritis, 
the effects of which were relatively equal in the two 
eyes. With these symptoms, so marked from the 
beginning, I was safe in assuming the case to be one 
of brain tumor. Of some special or localizing symp- 
tom, however, I was in doubt. There was the facial 
palsy, yet this had not remained constant in extent 
and duration. The pupillary reaction was paradoxic. 

4. There remained to be coniridered only the abducens 
palsy. I could not help regarding this as of importance 



62 American Medicine] 



CASE OF CEREBELLAR TUMOR 



C January 13, 190fi 
Vol. XI, No. 2 



in connection with the other factors, and particularly 
the optic neuritis, in spite of the uncertainty of the 
causation of this symptom. There is no cranial nerve 
so liable to provide a distant symptom as the sixth. The 
lengthened course which this nerve takes over the most 
prominent part of the pons renders it readily affected 
by distant pressure. (Gowers, quoted by Swanzy.) I 
was fascinated by the presence of this symptom, and I 
boldly ventured the diagnosis of cerebellar tumor. 

On December 27, the patient was admitted to the 
Germantown Hospital. Here he was confined to bed 
and a course of treatment was instituted, consisting of 
alteratives, diaphoretics, and salines. At the end of ten 
days the convergence and the diplopia had disappeared. 
The edema of the retina and venous engorgement 
became remarkably reduced, and no new hemorrhages 
were noted. The patient was then allowed to be out of 
bed, and was given the freedom of the ward. At no 
time was there vomiting or headaches, neither was there 
disturbance of locomotion nor change in station — of this 
there can be no doubt. The visual acuity of each eye 
remained unchanged. The optic papillas remained as 
prominent as at the earlier examinations. During the 
patient's stay in the hospital I was not a little surprised 
at the speedy regression of the symptoms. It was 
impossible for me even to guess at the kind of tumor 
contained within the cranial cavity. It surely was not 
an abscess'; there had been no rise of temperature, and 
abscess predisposes less to optic neuritis than tumor, 
and I was disinclined to believe it to be a gummatous 
tumor, and yet the prompt cessation of all the symp- 
toms, even the retina was less edematous, which fol- 
lowed upon the thorough mercurialization, threw my 
thoughts into confusion. I felt justified, however, in 
allowing the man to return to his home. 

On January 23, 1905, he was discharged from the hos- 
pital, and I saw him repeatedly at my office. On Feb- 
ruary 13, early in the morning, for the first time since 
December 20, 1904, there was an attack of vomiting, fol- 
lowed by much disturbance of the vision. At about 10 
o'clock the man came alone to my office. The optic 
nerve heads were greatly swollen ; the retina intensely 
edematous, while in the macular regions of each eye 
were large atrophic patches. On February 22, my notes 
record that he had indulged in walks of several miles 
without fatigue or disturbance of coordination. His 
wife had, in the meantime, begged me to forbid the tak- 
ing of these long walks, because her husband usually 
had restless nights after such prolonged exercise. On 
this day, Washington's Birthday, he again came to my 
office alone ; he very greatly enjoyed mingling with and 
watching the crowds surrounding the President, who 
was visiting the city. On February 26, he suffered from 
intense right-sided headaches, and Dr. McMullin was 
called. There had been short periods of semiconscious- 
ness, and Cheyne-Stokes' respiration, with irregular 
pulse. Two days later I met Dr. McMullin in consulta- 
tion, for on this day there had been tonic convulsive 
seizures involving the arms, with stiffness of the back of 
the neck, occipital pains and tenderness, and vomiting. 
At the hour I saw him, 9.30 p.m., he was absolutely free 
from all these symptoms; the pulse was slow and full; 
the grasp of the two hands strong and painful to me, 
and, except for the recollection of the frightful storm 
through which he had so recently passed, his cheerful 
disposition was unchanged. Neither fundus presented 
any new developments. I became all the more certain 
that there was a solid tumor at the base of the brain, 
located most probably in the cerebellar region. A re- 
turn to hospital treatment was advised. On Thursday, 
March 2, he was admitted to the Episcopal Hospital. 

On admission the man was found to be weak and 
debilitated, yet without actual loss of power in his ex- 
tremities. His intelligence was good and his memory 
retentive. The examination of the blood showed the 
presence of 4,240,000 red blood cells; 9,400 white blood 



cells, and 90^ hemoglobin. Neither albumin nor sugar 
was found in the urine. 

The vision of the right eye was 20/70, of the left 
20/200. The outward rotation of the left eye was some- 
what impaired owing to a paresis of the external rectus 
muscle. All movements of the right eye showed no im- 
pairment of tlie extraocular muscles. In neither eye 
were-nystagmic movements observed at any time. The 
pupils reacted normally to light, convergence and con- 
sensually. The fields of vision remained contracted. 
The ophthalmoscopic examination showed great swell- 
ing of the retina, many splotches of degeneration, and 
small linear hemorrhages, and projection of the optic 
discs to 6D. 

The cardinal symptoms complained of were head- 
ache, loss of vision, and nausea. There was spasticity of 
the muscles of the neck, with retraction of the head. No 
abnormal signs were obtained in the physical examina- 
tion of the thorax, while the pulse and temperature were 
normal. The man was put to bed, mercurial inunctions 
daily were ordered ; only a light diet was allowed. At 
once marked improvement in general health followed, 
and continued for 10 days. There were no attacks of 
vomiting, and but little nausea ; he was greatly relieved 
of his headaches and expressed himself as feeling decid- 
edly better. After two weeks the diet list was enlarged 
and potassium iodid in large increasing doses was pre- 
scribed. This lull was followed by a return of the storm 
in all its fury. The headaches were usually at the occi- 
put ; shooting pains starting from the left frontal re- 
gion radiated to the parietal and the occipital. The 
head was retracted. Attacks of nausea and vomiting 
become frequent. The ocular conditions remained un- 
changed. 

Shortly after admission, Drs. Davis, Stevens, and 
Ring examined the patient with Dr. Van Pelt, and con- 
curred in the opinion that the case was one of brain 
tumor, yet they hesitated to decide upon the probable 
location of the tumor because of the unsteadiness of any 
localizing symptom. 

On March 18, without loss of consciousness, there was 
a convulsion of the forearms, which lasted for several 
minutes ; the hands became firmly clenched and flexed, 
while the forearms were flexed on the arms. Relief 
followed after inhalations of chloroform. As the attack 
passed off the patient vomited. A similar yet less vio- 
lent attack followed on the next day, without vomiting, 
and three days later there was another seizure of shorter 
duration than the preceding ones. In this attack the 
patient was mildly rebuked by the nurse in charge, and 
requested to control himself. The convulsion immedi- 
ately ceased, and no similar nervous phenomenon 
followed. 

By this time the patient had become prostrated, the 
symptoms were greatly intensified, and the outlook 
more and more unfavorable. At night he was restless 
and delirious, while in the day he lay lethargic. On 
March 29, Dr. Wharton Sinkler was consulted. At this 
examination the patient could walk unattended, but in 
stepping forward he exhibited a distinct tendency to 
stagger and to fall towards the left side. The patellar 
reflexes were abolished. A diagnosis of cerebellar 
tumor was made with certainty, and the advisability of 
an operation to open the skull in the position best 
adapted for an exploration of the left cerebellar region 
was agreed upon. Consent for operation having been 
obtained from the patient's family, the man was trans- 
ferred to the service of Dr. Neilson, the attending sur- 
geon on duty, he having agreed to perform the 
operation. 

Unfortunately the diagnosis was not confirmed in 
the operation-room, but at the necropsy, for, on April 7, 
the patient was seized with a violent delirium, from 
which he fell into a comatose state, and died suddenly 
four hours after. 

Dr. Robertson, the pathologist of the hospital, was 



January 18, 1906T 
Vol. XI, No. 2 J 



AMERICAN HOOKWORM 



XAUBRicAN Medicine 63 



allowed to remove the brain, and Dr. Spiller has very 
kindly examined it. The result of his study of the 
tumor and the regions affected by it together with 
remarks upon the clinical course of this very sad case, 
I am most fortunately able to have him present to you 
at the conclusion of this report. 

It is interesting to speculate upon the probable result 
had operative procedures been instituted so soon as the 
abducens paralysis and the intraocular changes had 
become sufficiently pronounced to render the pre- 
sumptive diagnosis of a cerebellar tumor positive. 

In general, the symptoms were those of intracranial 
tumor of the hind-brain, rather than of the more for- 
ward portions. They appear to be those produced by 
irritation rather than by the destruction of the basilar 
centers. Although the intense papillitis was conclusive 
of the presence of a tumor, the indeflniteness of the 
other symptoms hindered the assumption that the tumor 
occupied the cerebellar region. The chief focal symp- 
toms were those of deviation of the optic axes, with 
disturbances of direct and binocular vision, and facial 
palsy ; yet, after energetic treatment the paresis of the 
left external rectus muscle, as well as the diplopia and 
the facial palsy, greatly disappeared, and when the man 
was placed under strict hospital regimen the general 
symptoms all but ceased, for there were no headaches, 
emesis, or muscular spasms, until the last course, after 
March 1. The gait, station, and the knee-jerks were 
not interfered with until very late in the progress of the 
malady. There was hyperexcitation of the sexual fuuc. 
tion almost until the end. The general bodily nutrition 
was maintained up to the last weeks of the man's life. 

REPORT BY DR. SPILLER. 

The tumor is situated upon the outer portion of the 
left lobe of the cerebellum, to which it is loosely 
attached. It is not at all infiltrating, but has made a 
depression in the left cerebellar lobe 2.5 cm. in depth. 
The tumor is very firm, almost globular, with some- 
what irregular surface, and does not appear to have been 
adherent to the dura. It is 4 cm. in width, 5.5 cm. in 
length, and 5 cm. in thickness from above downward. 
When cut it appears friable and resembles a fibrosar- 
coma. It has caused some pressure upon the fourth 
ventricle and thereby moderate internal hydrocephalus 
of the cerebrum, although the aqueduct of Sylvius is 
not much dilated and the fourth ventricle not at all. 
The third and lateral ventricles of the brain are mod- 
erately distended, especially the posterior horn of the 
left lateral ventricle, the floor of which is forced upward 
by the pressure of the tumor upon the under surface of 
the left occipital lobe. None of the cranial nerves is 
jmplicated in the tumor. The microscopic examination 
liows that the tumor is a fibrosarcoma. 

The specimen is one of much interest. We often 
perate on tumors of the cerebellum, but I think I have 
lever seen a tumor of the cerebellum which offered 
fore favorable conditions for operation than did this 
imor, situated as it was on the lateral portion of the 
ft cerebellar lobe, and not infiltrating the cerebellum 
I the least. From its location it would have been seen 
soon as an opening were made in the skull. The 
liances are that it would have been entirely removed, 
and that the patient would have recovered with no 
return of symptoms. As it is a fibrosarcoma and very 
hard, it is not likely that it would have recurred. Any- 
one interested in cerebral surgery cannot but deeply 
regret that operation could not have been done, as if 
it had been done the case would probably have been 



one of the most brilliant on record. It is striking that 
there should have been involvement of the left external 
rectus muscle, because none of the cranial nerves were 
directly implicated in the tumor. The tumor being on 
the left side of the cerebellum, it must have distorted 
the left sixth nerve more than the right. It is remark- 
able, that the right facial nerve was involved at all. The 
Improvement of symptoms under iodid and mercury 
does not mean that a tumor is a gumma. We are all 
familiar with the fact that the symptoms of tumor often 
disappear under the administration of mercury and 
iodid, at least for a time. The early choked disc and 
the character of the neuroretinitis might have suggested 
that the tumor was in the cerebellum. 



A YOUNG STAGE OF THE AMERICAN HOOKWORM 
—NEGATOR AMERICANUS (STILES, 1902)— 8 
TO 12 DAYS AFTER SKIN INFECTION IN RAB- 
BITS AND DOGS. 

BY 

CH. WARDELL STILES, Ph.D., 

Chief of Division of Zoology, Hygienic Laboratory, Uniled States Fab- 
lie Health and Marine-Hospital Service, 

AND 

JOSEPH GOLDBERGER, M.D., 

Passed Assistant Surgeon, United States Public Health and Marine- 
Hospital Service, 

of Washington, D. C. 

Dr. S. S. Adams, of Washington, D. C, recently 
sent us some feces from a patient with hookworm infec- 
tion, who was treated in his wards at the Children's 
Hospital. Hookworm eggs were present in consider- 
able number, but they were not so numerous as found in 
many other cases we have examined. These eggs were 
allowed to incubate and the infecting stage was then 
used to infect two rabbits and two dogs. 

The fluid from the cultures was dropped upon the 
back of the experiment animals, which were then kept 
under observation for several hours, every precaution ' 
being taken to prevent any infection by the mouth. The 
two rabbits were examined 8 and 9 days, respectively, 
after infection, the two dogs 12 days after infection. In 
all four cases young hookworms were found in the small 
intestine, and in one dog in the stomach also. These 
worms agree essentially in structure, and, although none 
of the infections were severe, no question arises in our 
minds regarding their being young hookworms. 

In length, five of the young parasites measured 0.92, 
0.96, 0.992, 1.29 and 1.64 mm.; the extremes (0.92 and 
1.64 mm.) were obtained from dogs, namely, 12 days 
after infection. The diameter in most cases did not ex- 
ceed 52.8 li, but the specimen 1.64 mm. long, gave a 
maximum diameter of 112 //; this diameter, however, 

' The technic uaed was not exactly the satne in all four cases. 
In some Instances the hair was shaved from the back of the 
animal, in other cases not; in some instances the culture 
medium itself was applied to the skin, in other cases water con- 
taining the larviB was dropped slowly on the skin ; in one case 
the animal was kept under morphin for about three hours, in 
the other cases they were simply secured in such a way as to 
exclude any possibility of soiling the mouth with the infec- 
tious material; in all cases the animals were kept under 
observation several hours, in order to prevent infection per 
mouth; tben the skin, at and around the point of infection, 
was thoroughly washed with alcohol and then dried, before the 
animals were returned to the kennels. Prom the extreme care 
exercised, we consider an accidental infection per mouth as ex- 
cluded. 



64 American Medicine] 



AMERICAN HOOKWOBM 



E January 13. 1906 
Vol. XI, no./ 



was obtained after the specimen was mounted, and un- 
doubtedly exceeds the normal. The cuticle shows a dis- 
tinct but very fine transverse striation. The mouth is 
terminal or practically so, for the dorsal curvature of the 
anterior end is evident in only a few cases, and then to 
only a very slight degree. In a specimen 0.992 mm. 
long, the cervical papillae are 162.8 /i from the anterior 
end, and the body is 50.6 /^ in diameter at this point ; in 
another specimen, from a dog, length not taken, the 
cervical papilhe are 220 /' from the anterior end. In 
only two specimens was the ventromedian excretory 
pore noticed, its location being about at the equator of 
the esophagus. The nerve ring is visible. The anus is 
on a slight elevation, with a semicircular opening, the 
concavity being directed caudad ; its distance from the 
tip of the tail varies in different specimens, the measure- 
ments obtained being 48.4 /;, 57.2 fi, 66 /i, 79.2 /i, and 88 /i. 
Caudad of the anus, the tail decreases in lateral diameter, 
at first rather gradually and regularly, but near its tip it 
decreases much more suddenly and ends in a fine point. 



observed. on the cuticle, but these have not yet been 
studied in detail. 

The esophagus varies some in size in the different 
specimens, as the following measurements show : 

198/' long, 22/' in diameter anteriorly, 48.4// in diam- 
eter posteriorly ; worm from a dog, 12 days after infec- 
tion. 

202/1 long, 22// in diameter anteriorly, 22// at equator, 
39.(i/' posteriorly ; worm 0.92 mm. long, from dog, 12 
days after infection. 

264// long, 26.4/1 in diameter, 141// from its buccal 
end, then it swells to 48.4// in diameter. 

288// long, worm 1.04 mm. long, from dog, 12 days 
after infection. 

290.4// long, .35.2/' in its greatest diameter. 

Length (?), 19.8// diameter anteriorly, 35.2// posteri- 
orly. 

Length (?), 26.4// diameter anteriorly, 26.4// at equa- 
tor, 50.6// posteriorly ; worm from dog, 12 days after in- 
fection. 

Thus, the esophagus varies from 198 to 290// in 
length. Its structure is entirely different from that of 






OMjoA ^ 




Figs. 1-2. — Two outlines of anterior portion of young specimens of Necator americanus, showing mouth, provisional buccal 
capsule, esophagus, and anterior portion of intestine; Fig. 1 also shows three teeth in the esophageal end of the buccal 
capsule, and the two cervical papillse ; Fig. 2 shows only two of the teeth. Greatly enlarged. Figs. 3-5.— Three outlines of 
the provisional buccal capsule of young specimens of Necator americanus, showing the paired ventral teeth and the unpaired 
dorsal tootli ; Fig. 5 is slightly damaged on one side, but it shows three oral papillse and one lip (?). Greatly enlarged. 
Fig. 6.— Outline of tail of young specimen of Necator americanus, to show position of the anus. Greatly enlarged. 



The buccal capsule varies in size, as the following 
measurements show : 35.2// long by 39.6 // in diameter; 
35.2 // long by 41.8 //'in diameter ; 39.6 // long by 39.6 // 
in diameter ; 39.6 /' long by 44 // in diameter ; 39.6 // long 
by 57.2 // in diameter ; 41.8 // long by 41.8 // in diameter ; 
41.8 // long by 52.4 // in diameter. 

One side of the capsule is slightly longer than the 
other ; in one case the longer side measured 44 // long, 
the shorter 39.6 // long. We interpret the longer side as 
ventral, the shorter as dorsal, as the longer side corre- 
sponded to the anal side in two specimens in which no 
torsion was visible ; and further, since it is the ventral 
side of the capsule, which is the longer, in the adult 
worm. Lips could not be recognized with absolute cer- 
tainty, but in one specimen in particular it appeared as 
if two delicate lips were present. Only three teeth (8.8 /< 
long) could be seen at the esophageal end of the buccal 
capsule ; two of these are situated, on the longer (ventral) 
surface, 'and hence would represent a pair of ventral 
lancets ; the third tooth is located on the shorter (dorsal) 
surface of the buccal capsule, thus corresponding in posi- 
tion to the "dorsomedian tooth " of the adult. 

On the anterior end of the body, several papillse were 



the larva, and resembles that of the adult form ; the an- 
terior portion is narrow while the posterior portion is 
swollen to nearly twice the diameter of the anterior end. 
Corresponding to this difference in diameter there is a 
great difference in its rigidity ; in moving around, the 
worm is able to bend the anterior portion of its body 
with the greatest facility, from its mouth to the point 
where the esophagus begins to swell, and the anterior 
narrower portion of the esophagus bends without diffi- 
culty, while the swollen posterior portion of the 
esophagus is much more rigid and corresponding to 
this, that portion of the body of the worm is much less 
agile. 

The intestine is well differentiated and at about the 
middle of its length the primordium of the genital 
organs was observed in several specimens; the sexes 
cannot be distinguished. 

The worm as described in the foregoing apparently 
corresponds to the stage of Agchylostovm duodenale 
described by IjOoss (1897) as the fourth stage (with pro- 
visional buccal capsule), namely, the stage following the 
third ecdysis. We observed no specimens in process of 
ecdysis, but the differences in structure between the 



JANUARY 13. 19061 

Vol. XI. No. 2 J 



PELVIOURETERAL LUMBAR IMPLANTATION iamkrican medio'nb 65 



stage here described and the infecting stage, justify tiie 
conclusion that ecdysis has occurred. 

In a former publication, Stiles (1903, p. 20) reported 
observations on the earlier stages of Necalor americanus 
as follows : 

Eggs may hatch the rhabditiform embryo in less than 
24 hours. (Claude A. Smith reports them as hatching 
in 12 to 24 hours or longer.) 

First stage (rhabditiform embryo) may be found in 
first ecdysis 2 to 3 days after hatching. 

Second stage may be found in second ecdysis 7 to 9 
days after hatching of first stage from the egg. This is 
now the infecting stage. 

The third stage of Necator americanus, namely, that 
resulting from the second ecdysis, has not yet been 
observed in the body. For Agchylostoma duodenale, 
Looss has shown that this stage may pass from the 
stomach to the small intestine ; it begins to feed, but its 
growth is slow ; after about five days it begins to show 
signs of the third ecdysis, which continues until about 
the seventh day ; upon casting its skin, the worm enters 
the— 

Fourth stage (with provisional buccal capsule). This 
is the stage now described for Necator americanus, as 
occurring 8 to 12 days after infection. These worms 
must next undergo a further (fourth) ecdysis, during 
which the sexes will become differentiated. In case of 
Agchylostoma duodenale, Looss states that this ecdysis 
occurs about 14 to 15 days after infection, when the 
worms enter the — 

Fifth stage (with definite buccal capsule), which then 
develops directly to the adult form. 

In one instance we were able to observe a young 
worm attach itself to a villus of the intestine, which 
happened to be on the slide ; the worm placed its mouth 
against the villus, and by repeated swallowing motions, 
drew, by suction, a portion of the villus down into the 
buccal capsule until it reached the lancets at the esoph- 
ageal end of the capsule; after retaining this position 
for about 15 minutes, the worm moved away from the 
villus. 

At this point in our observations our work was sud- 
denly interrupted by the yellow fever outbreak, and it 
may be some time before it can be carried further, but 
we publish this short note to show that (1) Both dogs 
and rabbits can be experimentally infected with a young 
intestinal stage of the American hookworm {Necalor 
americanus, sen Uncinaria americana) ; (2) if the infect- 
ing stage is placed upon the skin of the back, it pene- 
^^»tes the skin, and 8 to 12 days later it has reached the 
^■omach and small intestine, and has undergone changes 
^^Bndoubtedly with ecdysis) in its structure which differ- 
HBitiate it very distinctly from the infecting stage, but 
""lit these dates (8 to 12 days) the worm also differs rad- 

Billy from the adult stage. 
Although both rabbits and dogs may be infected 
ith this young stage, there is no evidence that these 
animals play any role in the spread of uncinariasis in 
man, for there is at present no evidence that these 
worms would reach maturity and reproduce in either 
the rabbit or the dog. 



SUBCUTANEOUS PELVIOURETERAL LUMBAR IM- 
PLANTATION, IN LIEU OF URETERECTOMY 
AFTER NEPHRECTOMY.' 

BY 

A. ERNEST GALLANT, M.D., 

of New York City. 

Professor of Gynecology, New York School for Clinical Medicine; 
Consulting Surgeon, Jamaica Hospital ; Assistant Gynecol- 
ogist, Koosevelt Hospital, Outpatient Depart- 
ment, etc. 

Is removal of the ureter after nephrectomy advisable, 
desirable, or necessary? My own answer to this impor- 
tant question can best be stated by a recital of the his- 
tory, method of operation, and outcome of the case 
which lead up to the conclusions hereafter stated. 

April 19, 1904, in response to a call from Dr. L. H. 
Moss, I saw Mrs. S., aged 29, mother of three children, 
the last born December 25, 1899, instrumental delivery. 
May 5, 1900, Dr. E. B. Cragin removed bilateral ovarian 
dermoids and left pyosalpinx, with the uterus. From 
April 10 to 16, 1904, she has been suffering with pleuritic 
pains in the right side, which have subsided. Three 
days ago, after fooling and jumping with the children, 
she felt something give on the right side, just below the 
chondral border, followed by a constant stitchlike, but 
not severe pain. Since the operation of four years ago, 
her right side has always been weak. 

Examination : Patient well nourished, somewhat 
anemic. Right kidney tender, lower pole palpable ; 
greater curvature of the stomach on a level with the 
umbilicus. Highest temperature yesterday, 103° F. 

Diagnosis: Hydronephrosis from prolapsed kidney. 
I elevated the foot of the bed and applied Rose's plaster 
binder. 

April 22 : Urinalysis showed pus and caudate and 
conical cells from the kidney pelvis, indicating pyelitis. 

April 24 : Cystoscopy showed bladder normal, urine 
discharging from the left ureter, but owing to a defective 
lamp I was unable to pass a catheter into the ureter. 

April 30 : Very few streptococci and staphylococci 
found in urine, and no tubercle bacilli. 

May 1 : Urine passed, 38 ounces ; May 2, 44 ounces. 

As the pain continued and the patient was losing 
ground, and the distention in the right loin continuing 
very great, it was decided to bring her to town, catheter- 
ize the ureters, and be guided by our findings. After 
considerable difficulty. Dr. W. Ayres succeeded in intro- 
ducing a catheter into the pelvis of the left ureter, with- 
drawing enough urine for examination. On the right 
side, however, the catheter could not be passed higher 
than four inches, nor could any urine be drained there- 
from. 

Diagnosis : Ureteral stricture in scar of former opera- 
tion. Dr. Louis Heitzman reported that the catheter 
specimen from left ureter showed pyelitis. 

Operation was done May 23, at 7.45 a. m. Pulse 92, 
temperature 99° F. Dr. Ayres assisted. Dr. Moss ad- 
ministered ether. An oblique incision, six inches long, 
was made through the skin and through the muscles and 
fascias b.y splitting with the fingers. On attempting to 
free the kidney, a perinephritic abscess at its anterior 
and upper part was opened. The enlarged kidney 
(6x4x2 j) pelvis, and ureter were very markedly dis- 
tended down to and below the pelvic brim. After 
freeing the kidney, its size was diminished by drawing 
off several ounces of purulent fluid, and the artery and 
veins ligated with black silk. After cutting the kidney 
free from the ureter, a probe was introduced down to a 
point apparently corresponding to that at which the 
catheter was blocked from below. 

' Read before the Surgical Section, New York Academy of 
Medicine, October 6, 1905. 



66 



AMKRicAN mkdicini:! pelvioureteral lumbar implantation 



rjANU-ARY 18, ]tm 
LVOL. XI, No. 2 




The ureter was sutured into the lower angle of the 
lumbar wound, its mouth opening outside the lumbar 
fascia, into the subcutaneous fatty tissue. The muscles 
were sutured in three tiers, and a gauze drain carried 
down to the vascular stump. A small wick of gauze 
was inserted into the mouth of the ureter and brought 
out on the surface. The skin was partially closed with 
silkwormgut, and dressed with balsam oil. 

After a rather stormy first week the pulse and tem- 
perature subsided, the discharge diminished, and the 
general condition rapidly improved, so that on the tenth 
day she sat up in a chair for 45 minutes, and on June 7, 
the fourteenth day after operation, returned to her home 
on Long Island, the discharge having almost ceased. 

On June 10, Dr. Moss found both openings closed 
and temperature 103° F. Both points were reopened 
and considerable pus let out, the temperature dropped, 
and the patient was able to get about the house. August 
29, the black silk ligatures were extruded from the wound, 
which closed again in September. The last of the silk 

ligatures was extruded 
in December, 1904, and 
the wound has been 
quiescent ever since. 

The patient's height 
is 5 feet 1 inch. Im- 
mediately after opera- 
tion she weighed 100 
pounds. At this writ- 
ing she weighs 135} 
pounds, and is in ex- 
cellent health. 

Schede'says: "That 
while removal of the 
whole (tuberculous) 
ureter is desirable, it 
adds considerable risk 
to an operation which 
is already severe, and 
the prolonging of the 
narcosis may have a 
serious effect upon the 
remaining kidney. 
There is also reason to 
suppose that tubercu- 
losis of the ureter may 
disappear spontaneous- 
ly when the affected 
kidney has been removed. Therefore, Schede extirpates 
the ureter so far as this can conveniently be done, and 
sutures its stump in the lower angle of the wound after 
cureting away the mucous membrane and burning the 
lumen with the Paquelin cautery. The ureteral stump 
is later treated with injections of iodoform, lactic acid, 
etc. He followed this treatment in 22 cases after extir- 
pation of a tuberculous kidney, and of the 16 patients 
who recovered not one was troubled with a permanent 
fistula." 

Schede ' also states : ' ' Whenever primary or second- 
ary nephrectomy is carried out, it is well not to bury the 
ligated ureter, but to suture it into the wound. One will 
thus avoid the unpleasant formation of a ' ureteral 
empyema.' This action is especially necessary when 
there is obstruction between the kidney and the bladder. 
Still, suture of the ureter in the wound does not always 
prevent retention of pus, which will sometimes require 
total extirpation of the ureter. The daily discharge of 



A, ureter ; B, stump of renal pelvis 
sutured to lumbar fascia ; C, drain- 
age-tube; D, skin; E, suboutaneous 
fat; F, lumbar fascia; G, lumbar 
muscles. 



a few drops of purulent secretion from such a ureter 
will give the patient little trouble." 

TechniG of Subcutaneous Lumbar Pelvioureteral Im- 
plantation.— After the kidney has been delivered and 
the renal vessels securely ligated (occasionally it may be 
necessary to expose the ureter and pelvis and resect be- 
fore tying the vessels), the kidney is freed from the 
ureter by cutting across the pelvis at about an inch above 
its junction with the ureter, thus leaving a funnel- 
shaped opening into the ureter which must be sutured 
to the lumbar fascia in such a way that the mouth is not 
exposed on the skin surface, but opens into the subcu- 
taneous fatty tissue. The flaring of the funnel makes 
suturing very simple ; the introduction of a drainage- 
tube easy ; and the mouth does not contract. When the 
discharge ceases the skin readily closes over the outlet 
and buries it, but should pus or mucus reaccumulate. a 
simple incision through the cuticle releases the pus, and 
drainage can again be established. Refilling is an- 
nounced by pain, fever, and bulging at the site of the 
implanted ureter, but by this method there can be no 
involvement of the retrocolonic space nor any of the 
deep structures. 

Vaginal Implantation of the Ureter.— After nephrec- 
tomy for tuberculous kidney, pyonephrosis without 
ureteral obstruction, it might be well to afford additional 
drainage and divert the ureteral secretion from the blad- 
der by resection of the vesical end (after introducing a 
catheter into the ureter), exposing the ureter, through 
the vaginal wall, cutting across, closing the vesical 
stump, and suturing the proximal end into the vaginal 
wound, that the ureter may drain directly into the 
vagina, where it can do no harm. 

Subcutaneous lumbar pelvioureteral implantation ap- 
peals to me as being simple, safe, and satisfactory, in 
that by this procedure we (1) avoid the additional risk 
of immediate ureterectomy ; (2) secure free drainage 
and maintain an opening through which drugs may be 
introduced to hasten retrograde changes; (3) on the 
other hand, the opening being beneath the skin does 
not prevent primary union ; avoids exposure on the skin 
surface; should mucus or pus accumulate it cannot 
burrow in the retrocolonic space, is easily recognized and 
let out through a small skin incision and a tube inserted 
for drainage ; the absence of ligature on the ureter pre- 
vents deep inflammation, and if the ureter must for any 
reason be subsequently removed it can be accomplished 
without difiiculty, from a patient who has had ample 
time to recuperate from the primary operation. The 
presence of the drainage-tube in the ureter, with or 
without the vaginal implantation, does not interfere 
with the patient in getting out of bed at an early date 
after operation, nor the exercise of her usual home duties. 
The only precaution necessary is to see that the skin 
opening is not permitted to close so long as the discharge 
persists, but the presence of a drainage-tube and dress- 
ing in no way interferes with the pursuit of the patient's 
usual vocation, or pleasures. However, if the opening 
does close and secretion reaccumulates in the ureter, the 
patient will suffer pain, a rise of temperature, and bulg- 
ing of the skin over the site of the ureteral opening. A 
small incision through the cuticle will at once give 



JANU>KY 13, 1906"! 

Vol. XI, No. 2 J 



DECEPTION AND FALSEHOOD 



AMBKicAN Medicine 67 



relief, and a tiny drainage-tube facilitate the exit of 
mucus or pus. As atrophic changes in the ureter take 
place, the secretion will cease and the opening will close 
permanently. 

BIBLIOGRAPHY. 

1 Bull's translation of Von Bergmann's Surgery, vol. v, 
p. 332. 

•■"Loc. cit., p. 292. 



DECEPTION AND FALSEHOOD AS PATHOLOGIC 
PHENOMENA. 

BY 

ALFRED GORDON, M.D., 

or Philadelphia. 

Chief of the Neurologic CUnifi, Jefferson Medical College; Examiner of 

the Insane at the Philadelphia General Hospital : Neurologist 

to Douglass Memorial Hospital. 

In normal life there are occasions when telling an 
untruth is a necessity, as for example, in cases in which 
the instinct of preservation demands it. Normally, 
lying is an act performed with a certain reasonable 
motive and in proportion with the cause. But when it 
is done without a sufficient motive, when it is persistent 
and out of proportion with the cause, when it is done 
against the individual's own interest, in other words, 
when it is illogical, such a phenomenon should certainly 
be considered morbid. However, the latter condition 
is observed at a certain period of normal life, viz., in 
infancy. At this age the psychic domain is extremely 
limited ; power of criticism and power of control are 
wanting. The child leads a life full of creative imagina- 
tion and free from inhibition ; the child is extremely 
subject to suggestion. Exaggeration, misrepresentation 
of facts, recital of impossible and never occurring events, 
are in a child all the result of errors of perception and 
misinterpretation. 

The lies, which, as we have seen, are a natural 
product of the rich and vivid imagination and suggesti- 
bility, gradually take the place of the conception of 
truth, and finally eliminate it completely ; autosugges- 
tion is the consequence. The latter condition leads to 
simulation, which is a lie of a higher and more complex 
order. At first, therefore, the act is involuntary, but 
later becomes voluntary. Facts of this character are 
abundant in psychologic literature. Duprat cites a case 
of a little girl of 4, who, after having been present at 
the departure of a steamer from a port, gives a most 
detailed account of all the adventures that occurred to 
her during her (imaginary) voyage on a ship. Another 
little girl imagined the death of her little sister (which 
was incorrect) just for the pleasure of being consoled. 

This condition makes its appearance in a child from 
the moment the psychic life becomes active, increases 
gradually during the first few years, but then imper- 
ceptibly decreases, and disappears at puberty in normal 
individuals. This is a natural physiologic cycle of 
events. Should the condition persist instead of dis- 
appearing, we have then to deal with a pathologic con- 
dition. The subject is of great practical importance 
from diagnostic, therapeutic, and medicolegal stand- 
points. 

A pathologic tendency for exaggeration, for telling 



untruths, for inventing impossible events, may be pres- 
ent in an adult as well as in a child. In both cases it 
can be considered as a stigma of mental degeneration. 
What characterizes it, is the duration, the intensity of 
the morbid condition, and mainly the association of this 
morbid activity with other degenerative features in the 
intellectual and moral spheres ; the latter influence the 
first, inspire and direct its acts, excite vicious or per- 
verted desires. 

Various forms of cerebral abiogenesis, manifesting 
during life general mental arrest and idiocy, embrace 
among other symptoms also those pertaining to our 
subject. Men that had unusually large opportunities to 
observe idiots, like Bourneville, for example, state that 
deception and falsehoods are precocious symptoms. But 
there is a far larger class of young individuals, socalled 
degenerates, who present these morbid symptoms to a 
more pronounced degree. These intellectual weaklings 
do not progress with their age; they are psychically 
infants, are deprived of power of reasoning, of criticism. 
They are easily influenced, they are highly suggestible. 
While in some cases these youths show the tendency for 
lying, for misrepresenting facts, etc., a tendency which 
leads to harmless consequences, in another group of 
cases the brutal and perverted instinct is the main 
feature. In the latter case, malice, hatred, jealousy, re- 
vengefulness, cruelty, desire for destruction, are the 
manifestations of such young degenerates. These young 
monstrosities show a precocious criminal instinct, which 
is so important properly to interpret from a legal stand- 
point. We find in medicolegal literature abundant 
examples of accusations made by children against 
parents ; they do not hesitate to accuse the latter of 
most monstrous crimes. I remember the case of a little 
girl who, having a grudge against a brother who fright- 
ened her, accused him falsely of assault— the act of 
which she described in minutest details, to the horror of 
the audience. Vanity, the great desire for notoriety, is 
another reason for telling falsehoods in these perverted 
individuals. Dupr6,' who made a special study of this 
subject, cites among other examples the case of a little 
girl who accused a perfectly innocent man of an assault. 
A close questioning disclosed that it was a falsehood, 
and she explained the reason of her lying by her great 
desire to appear in public before the coroner, as this was 
so much praised by her friend a short time before the 
inquest. 

If we now turn our attention to adults, we find the 
spontaneous and constant tendency to falsehood and 
deception mentioned mostly in young individuals and 
again in those qualified as degenerates. The difference 
between the adult and the child lies in the degree. 
Although such adults present an infantile intellect, but 
the effect of years' observation renders them more profi- 
cient in accentuating the morbid tendencies described. 
There is an additional phenomenon, which is not at all 
or very exceptionally observed in children, but met in 
adults, viz., autoaccusation, which sometimes assumes a 
criminal character. In order to deceive and ridicule 
authorities, physicians, public opinion, and enjoy the 
effect of their lies, they will accuse themselves of the 
' Bull. M^d., 1905, No. 23. 



68 A^MBHICAN MkDICINKI 



CRIMINAL PROCEDURE IN POISON CASES 



rjANUABY 13, 1906 

LVOL. XI, No. 2 



most improbable crimes, which they have perhaps read 
in the press immediately before. 

I have said that mentally defective children are par- 
ticularly inclined to autosuggestion. The same feature 
is observed in adults. Cases of imaginary assaults told 
by the victims in the most picturesque manner, are 
abundant in medicolegal literature. This crime is ap- 
parently the most favored among women. The reason 
of it probably lies in the interest, curiosity and sympathy 
manifested in public opinion for the unfortunate victim. 
Frequently these women are happy, feel flattered to 
come to public notice. 

Vanity, moral perversity, deception practised in the 
manner as indicated, are symptoms of a pathologic con- 
dition ; they are closely allied to mental degeneracy and 
loss of psychic equilibrium, they are manifestations of 
the socalled " moral insanity." However, there is a 
certain relationship between these symptoms and hys- 
teria. Suggestibility, autosuggestion, simulation, are 
all met in this great neurosis, but they are usually pro- 
duced involuntarily or unconsciously, while vicious ten- 
dencies, falsehood, deception and simulation, accom- 
plished intentionally and consciously, belong to an 
entirely different order of psychic disturbances than 
hysteria. The latter are the result of an originally 
abnormal psychic make-up. The practical importance of 
this knowledge is too obvious to dwell upon. The med- 
icolegal deductions of this study are of the highest soei- 
ologic interest. We have seen first of all how much 
reliance we can place on testimony of children. In such 
cases, the element of suggestion should always be taken 
into consideration. Monstrous accusations, autoaccusa- 
tions should be thoroughly investigated, should always 
be looked upon with suspicion and placed in the hands 
of medical experts. It is the alienist that should decide 
upon such cases, as they belong entirely to the domain 
of medicolegal psychiatry. It is true that public opinion 
is not yet prepared to consider as mentally diseased, indi- 
viduals who are capable of combining various forms of 
perversion with intellectual resourcefulness, but alienists 
should unceasingly continue to work against such mis- 
conceptions, and in the name of justice, correct legal 
errors when responsibility is recognized in individuals 
who are not responsible for their crimes. 



SPECIAL ARTICLES 



The Creeks' Medicine Man. — The medicine man 
of the Creeks will not eat anything scorched in cooking ; 
in treating a gun or arrow-shot wound he as well as the 
patient will fast four days, only drinking a little gruel. 
He will not allow a woman to look at his patient until 
he is well or dead. If his patient dies the medicine man 
takes a lot of medicine himself in order to cleanse him- 
self from the fumes or odor of the dead. The pall- 
bearers, as we might call those assisting in the burial, 
also take the same cleansing process. And again when 
an Indian committed murder, even in self defense, he 
went to the medicine man and took the cleansing rem- 
edy, claiming the remedy appeased the crime and the 
trouble to his mind. The medicine man has a horror of 
women, keeping out of their company as much as pos- 
sible. At the full of each moon it was the custom of the 
bucks to drink medicine made by the medicine man to 
cleanse their systems. In camp the Indian killed noth- 
ing which was not eatable. — The Indian Journal. 



THE MEDICOLEGAL ASPECT AND CRIMINAL PRO- 
CEDURE IN THE POISON CASES OF THE SIX- 
TEENTH CENTURY. 

BY 

CHARLES GREENE CUMSTON, M.D., 

of Boston, Mass. 

Member of the Medical Historical Society of France, etc. 

In the long chain of history one is constantly meet- 
ing mysterious deaths seizing vigorous people in robust 
health. The subjects usually occupy some high position 
and disappear just at the time when their presence be- 
comes an obstacle to an heir or a competitor. One imme- 
diately has the feeling that all these deaths are merely 
instances of homicide, although there are no absolute 
proofs in favor of this hypothesis. Blood was not shed, 
the sword leaves no trace, nobody saw the assassin ac- 
complish his crime, and, nevertheless, general opinion 
refuses to believe that all these victims died natural 
deaths. They designate certain people by the terrible 
and detested name of poisoner. In point of fact, poison 
has played a great part in history and was a much too 
convenient arm to be left aside, and it is always found 
in the hands of those who, devoured by ambition, had 
not the courage to end their desire by the price of an 
outright murder. The latter had the misfortune of leav- 
ing some trace behind, which, sooner or later, would de- 
nounce the culprit, while poison would only leave a 
doubt as to the true nature of death, and, for this reason, 
in all times it was employed in order to avoid intrigue. 
Poison was the arm of the aristocracy, and kings did not 
disdain it, so that an example starting from so high a 
source was naturally followed by the courtesans in the 
first place and the people afterwards. 

The true home of poison was the Orient, and the 
princes of Asia, tired of bloody spectacles, searched for 
new voluptuousness by witnessing the effects of poison 
given to their slaves, and consequently the history of 
Asia represents a long chain of dramas from death by 
poisoning. From the Orient this method came to Greece, 
but without making much impression there, because the 
loyalty of this people made them repugnant to such 
crimes, and they reserved poison for those they wished 
to put to death legally. In imperial Rome, things were 
not the same, and the then reigning conditions repre- 
sented an essentially favorable midst for the develop- 
ment of homicide by poisoning, and such instances rap- 
idly became numerous. During the Middle Ages this 
crime appeared to be rare in France. This, however, 
does not mean that poisons were not known, because 
their use has never been forgotten, but they were hardly 
employed anywhere but at the Court and by high per- 
sonages. Among the people, sorcerers were the only 
ones to resort to their use, and the ointments that they 
prepared only occasionally resulted in accidental death. 
Suddenly, without hardly any transition, the Renais- 
sance came to light. The Italians invaded France, giv- 
ing this country all the great advances that the former 
had made in the culture of arts and sciences, but at the 
same time they brought with them their deplorable 



January 13, 1906"] 
VOL. XI, No. 2 J 



CRIMINAL PROCEDURE IN POISON CASES 



[American Mkdicinr 69 



I 



morals. Sensual and artistic, the princes of the Italian 
courts searched for art even in the way of giving death. 
To the grossness of the sword, which struck too openly, 
they preferred poison, which slowly infiltrated the veins 
and killed the strongest in the midst of feasts and fetes, 
without the loss of a drop of blood. They taught to 
France the most refined means of getting rid of those who 
came in the way, and they showed all the advantages 
derived from mineral poisons and taught the secret of 
the fearful poisonous compositions. 

Catherine de Mfidicis arrived at the court of France 
followed by a band of devoted Italiancourtiers,who would 
obey any order, no matter what its nature, that she 
might give. She belonged to a family who had become 
sadly celebrated by the innumerable forfeits that it ac- 
complished, and especially by its murders from poison. 
At the court she continued the traditions of her ances- 
tors with the aid of the Florentine Ren6, who furnished 
her all the necessary poisons for the accomplishment of 
her designs. All the high positions were occupied by 
Italians, who brought the customs of their country into 
use. Poison was immediately chosen as one of the most 
suitable arms, all the more so as it assured impunity to 
the culprit. 

In point of fact, physicians were at this time unable 
to recognize its traces in the cadaver, and autopsies only 
gave very vague information, while experimental re- 
searches had not as yet given the medical profession its 
precious concourse. Medical men occasionally were able 
to establish the reality of a death by poison, but they 
hesitated to announce the fact, because the discovery of 
the criminal might bring the hatred of some high per- 
sonage upon them, whose influence was necessary. It 
was among the aristocracy that the poisoning habit first 
developed, and the court adopted this means with eager- 
ness, so that the judgment that Tr6moille handed down 
regarding it was never so true as during the Renais- 
sance, which represented a combination of greatness and 
baseness. "The Court is an ambitious humility, a lu- 
bric chastity, a furious moderation, a tiresome love, a 
corrupted justice, a hungry abundance, a miserable high- 
ness, a state without security, a contempt of virtue, an 
exaltation of vice, a dying life and living death ; the 
highest are in greater danger than the lowly, because 
fortune does not smile upon the security of the great." 

From the court poisoning reached Paris and the 
nobles imported this crime into the provinces, but it is 
not probable that it penetrated into the country, and it 
is more likely that the peasants, as at the present time, 
used their natural arms to settle their quarrels without 
having recourse to these complicated procedures. 

What was the role played by the physician in cases 
of poisoning, what means he had in his possession to 
detect the trace of poison, and what help could the med- 
ical art give to justice in the sixteenth century are all 
questions which are most interesting to solve, because it 
was at this time that forensic medicine was created. It 
wa.s to the genius of Ambroise Par6 and his students. 
Cardan and Porta, that this science was brought out 
from obscurity and the immense service that it has since 
rendered to justice is well known. It had not at that 
time all those means of investigation which it today pos- 



sesses, but one is obliged to admit that it acquired a very 
rapid development, and that from its very commence- 
ment it was attentively followed by the legal profession. 
Without attaining the proportions that it reached during 
the following century, homicide by poison had become 
sufficiently frequent for justice to become disturbed and 
it formulated special laws and punishments. Jousse, in 
his " Trait6 de la justice ciaminelle en France," pub- 
lished at Paris in 1771, tells us that the judges under- 
stood by the word poison "all drugs or chemic prepa- 
rations capable of giving rise to death," and by poisoners, 
"those who employed these means for killing other 
people." Love philters and abortive drinks were not 
considered, properly speaking, as poison, but they 
entered under this head when they caused the death of 
people to whom they had been given. 

This definition having been established, let us con- 
sider how the criminal procedure at this epoch was car- 
ried out. When a person in perfect health was suddenly 
stricken by illness, especially when this occurred after a 
repast, opinion was never wanting to attribute the death 
as the result of a crime. As traces of violence could 
never be detected, these deaths were immediately placed 
in the long list of the poison dramas. The news circu- 
lated from mouth to mouth and the criminal was not 
long in being indicated under breath. In possession of 
these suspicions, justice immediately commenced an in- 
quest, and its first act was to designate the physician to 
examine the victim. 

One of two cases was then presented ; there had 
been only a simple attempt, and the person to be exam- 
ined was living and could himself give all the necessary 
knowledge to the physician, or, on the other hand, the 
victim had died, and an autopsy alone could verify or 
destroy all suspicion of poisoning. In the former case 
the physician based his opinion on the symptoms of 
poisoning, which, according to Ambroise Pare, were the 
following : 

We recognize that a man has been poisoned, no matter in 
what way, when he complains of a great weight throughout the 
body, which makes him displeasing to himself; when the 
stomach gives him some horrible taste in the mouth, entirely 
different than that derived from ordinary meat, no matter how 
bad it may be ; when the color of the face changes, being either 
livid or yellow, or any other strange tint, and deformed ; when 
he complains of nausea and the desire to vomit; when he is 
possessed of an uneasiness of the entire body, and it seems that 
everything about him is turned upside down ; when without 
appearance of great or marked heat or cold, the patient falls 
from heart weakness accompanied by a cold sweat. 

To these symptoms, which were always observed, 
other particular signs were noted with each kind of 
poison, which sometimes allowed the diagnosis of the 
substance given to be made. Beside the physician found 
a precious auxiliary in the examination of the vomited 
matter, but at this epoch, chemic research being un- 
known, this examination was merely an illusion. This 
can readily be seen because it would be very difficult to 
recognize the nature of a poison by the color and odor of 
the stnma^ih contents, but nevertheless physicians could 
establish the reality of death by poisoning by the pro- 
cedures that we have mentioned, which, at this time, 
were the only ones which could be utilized. 



70 A.MKRICAN MkDICINEI 



CRIMINAL PROCEDURE IN POISON CASES 



rJANOAEY IS, 1906 

LvoL. XI, No. 2 



When the victim had died, an autopsy was performed, 
and if the body was livid, covered with spots, exhaling 
a very bad odor, with black nails, which were hardly 
attached to the fingers, with foam at the mouth, there 
were already very strong presumptions in favor ofdeath 
by poisoning. If examination of the interior of the 
body revealed indications of corrosions in the esophagus 
or stomach, black spots in the intestines, and congealed 
blood around the heart or in the stomach, there was no 
longer any doubt, so that the hypothesis was fully con- 
firmed. If the poison was found in any of the organs it 
was sometimes experimented with on animals. All 
these means were extremely small in order to make so 
serious an accusation, but the physician of the sixteenth 
century could not do more than what the progress of 
science had up to that time taught them. Toxicology 
was at this epoch absolutely unknown, and it was only 
later, under the influence of all the serious cases ofdeath 
by poison, that it was Anally built upon solid basis. 

When in possession of these facts the physician wrote 
out a report which was handed over to the courts and, as 
an example of one of these, I here translate one given 
by Ambroise Par6 in his work : 

M. de Castellan, physician in ordinary to the king, and 
master Jean d'Amboise, surgeon in ordinary to the king, and 
tnyself, were sent to open the body of a certain personage ttiat 
one suspected of having been poisoned, because, before having 
supped he had not complained of any pain. And soon after 
supper he complained of a severe pain in the stomach, crying 
out that he was suffocating, and the entire body became 
yellow and swollen, unable to breathe and panting like a 
dog who had ran a long distance; because the diaphragm 
(principal instrument for the respiration) being unable to 
have its natural movement redoubled its action and thus 
hastened the course of respiration and expiration; then 
he had vertigo, spasm, and failing of the heart and 
consequently death. Now in truth in the morning we were 
shown a dead body, which was completely swollen just like a 
sheep that had .been blown up in order to be skinned. The said 
d'Amboise made the first incision, while I withdrew behind, 
knowing that a cadaverous and stinking exhalation would 
come out, this which did occur, and which all those present 
could hardly endure; the intestine, and generally all the inter- 
nal parts were greatly blown out and filled with air ; and thus 
we found a large quantity of blood which had escaped into the 
entrails and the cavity of the thorax, and it was concluded that 
the said personage might have been poisoned by the crapsudin 
poison. 

I will now give another medicolegal report, although 
it was written much later, because it shows to greater 
advantage than the preceding one, which in reality is 
merely a simple recital of an autopsy, how those reports 
were made out. I translate it from " Doctrine des rap- 
ports de chirurgie" by Nicholas de B16gny, published at 
Lyons in 1684. 

Reported by us, master surgeons sworn. In the city and 
jurisdiction of Lyons, that this day, September 18, 1682, in exe- 
cution of the ordinance of the Lieutenant General, we went to 
rue des Landes, in a house which bears as sign the image of 
Saint Margaret, in order to visit the dead body of Suzanne Fer- 
net, a sworn matron, having found all the external parts in 
their natural position, we then proceeded to the opening of her 
body in the presence of master Claude du Pradel, doctor of 
medicine, appointed to the place by the Lieutenant-General ; 
and having commenced by the abdomen and afterwards opened 
the stomach, we found it completely cauterized in its fundus, 
which contained a black, sandy liquid in quantity about as 
much as an eggful, which, having been placed by us in a metal 



vessel, stained it, as would be done by acid and corrosive 
liquids and which having been given in a small quantity to a 
dog, acted on him severely, as we were able to recognize by his 
cries and howling, all of which made us consider that the said 
Fernet had been poisoned by arsenic or sublimate, or other 
such corrosive poisons of the mineral gender ; in which we 
were all the more confirmed by the excellent condition of all 
the other intestinal parts, as much in the abdomen as in the 
chest and head, which we had likewise opened, and where we 
found no cause for death, all of which we certify as true, in faith 
of which we have, with the said Master du Fradel, signed the 
present report, in order that it may serve whom it may concern. 
At Lyons the day and year mentioned above. 

From these examples of medicolegal reports it at 
once becomes evident how little knowledge was gained 
by autopsies. The doubt still remained in suspense, and 
this is quite enough to explain the true reasons for the 
great number of deaths by poisoning in the sixteenth 
and seventeenth centuries. The accused, in spite of the 
most serious presumptions, always was hopeful of escap- 
ing death, because his guilt was always doubtful and 
the charges accumulated against him rarely resulted in 
an absolute certitude of his guilt. For this reason it was 
not until toxicologic researches had been carried out that 
the development of this form of crime could be stopped, 
which at the present time is one of the least frequent 
causes of criminal homicide. Arsenic, which was then 
the king of poisons, has since been almost completely 
given up by criminals, because toxicology allows one to 
discover the most infinite traces in the cadaver of the 
victim. 

The penalties applied to poisoners varied according to 
the country, but in general these criminals were con- 
demned to death and the type of execution only varied 
according to the local customs. It is to be remarked in 
the first place that in most instances the crime was com- 
mitted by women, which is easily explained, because on 
account of the weakness of their sex they could not re- 
venge themselves by the use of arms. The poison was 
a hidden arm, striking with certitude, and which per- 
fectly fulfilled the natural dissimulation of their sex. 
Consequently, one continually finds in the texts of the 
epoch a distinction between the penalty applied to 
women and that to which men were subjected. Accord- 
ing to the Caroline Constitution, Article 130, he who 
had attempted to take the life of another by poison 
was condemned to death. If the criminal was a 
man, he died on the wheel like a vulgar assassin, while 
if it was a woman, she was thrown into the water. It 
was also specified that the criminals should be dragged 
to the place of execution and that before the execution 
took place they should be more or less subjected to hot 
irons, according to their condition and the circumstances 
of the crime. In France the penalty of death was also 
inflicted to poisoners, while the type of execution varied 
according to the circumstances and also to the local 
customs. Sometimes they were convicted and sentenced 
to be burned. The closer the degree of relationship ex- 
isting between the accused and tlie victim also was con- 
sidered in giving the sentence, and a son who poisoned 
his fatlier or his mother was punished as a parricide, 
and parents who poisoned their children or wives their 
husbands, entered under the same class. 

The law established distinctions between those who 



JANUARY 13, ]906-| 

Vol. XI, No. 2 J 



CRIMIKAL PROCEDURE IN POISON CASES 



[American Mbdicinb 71 



sold the poison and those who administered It, and in 
the same sense, it did not inflict the same sentence to 
those who had caused the death of their victim and 
those who had simply committed a mere attempt. All 
these laws are to be found exposed in Farinacius, and 
we will here reproduce them as they are given by 
Jousse : 

It is, however, necessary to observe respecting those who 
prepare or distribute poisons for the purpose of poisoning 
somebody, or who buy poison with the same intention, that 
they should not be punished by the sentence of death only 
when they reduce their design in act, by doing something 
which may tend to cause death ; and in respect to those who 
sell and distribute it, knowing the use that one will make, they 
should not be punished with the ordinary laws applicable to 
poison, only when the design of him who wished to poison has 
been placed in execution and followed by death, otherwise they 
should be punished by a lighter sentence (Menochius). 

If he who has bought, composed, or prepared poison, in 
order to poison somebody, has not put his design into execu- 
tion because he has been prevented, he should not be punished 
by the sentence of death, but only by a less serious punish- 
ment, according to the circumstances and the quality of the 
person. 

For a still greater reason, this should be the case when it is 
repentance that prevented him from executing his design, and 
in the second case, the punishment should be still less than in 
the preceding case. 

Such were the legal dispositions relating to poison- 
ing, followed by death and to simple attempLs. Physi- 
cians, apothecaries, veterinarians, and, in general, all 
people who, from their business, kept toxic substances, 
were allowed to sell them, but before giving them to a 
buyer, they should inquire as to the honesty of their 
client and the use to which he intended to put them. If 
these precautions were not taken and death followed, he 
who sold the poison was brought to trial in nearly the 
same capacity as the one who had administered it, and 
in many cases he was condemned to undergo the same 
sentence. Justice also applied laws to those who had 
committed several murders by poison, and the following 
are, according to Farinacius, the penalties that were 
applied to them : 

Relative to those who poison the water of a well, or a foun- 
tain, in order to kill those who may drink at these places, they 
should be punished as homicides ; and this should not suffer 
any difficulty, when somebody has drunk the water from this 
well, or from this fountain, which has caused death. But, if 
this occurred accidentally, it appears that the accused should 
not be punished by a death sentence, but only by some other 
arbitrary sentence. 

As a conclu.sion to all that we have said relative to 
the laws applicable to criminal poisoners, I would quote 
the two following judgments rendered by the courts. 
By a judgment handed down July 15, 1585, and related 
by Imbert, in his *' Institutiones Foren.ses," a young 
woman of Paris, named Marie Lejuge, daughter of a 
merchant in the same city. Was hung and burned for 
having poisoned her husband, this act resulting from a 
blow that he had given her. In another decision handed 
down by the criminal court of Orl6ans on September 12, 
1602, a young woman of 14J years was convicted of 
poisoning her husband, who died, and she was con- 
demned to be hung, her body burned, and her ashes 
thrown to the winds. She had given arsenic in milk to 
her husband after having been seduced by the curO of 



the place. The curb's servant having been convicted 
for preparing the arsenic was, on Saturday, September 
26, of the same year, condemned to be hu'ng by the de- 
cision of the court, and was executed in the Place du 
Martroi d'Orleans, on Monday, October 26, of the same 
year. The curate, condemned for incest with this young 
woman, his parishioner, was condemned to be burned 
alive, and the decision was at once executed. 

I can hardly terminate this chapter without making 
a few remarks relative to the legislation of love philters 
and abortive drinks, the following being the article of 
the Canon law relative to this question : 

Those who give an abortive drink, or a love philter, even 
although they may cause no harm, and simply because the 
thing is a bad example, the culprits shall be condemned to the 
mines when in low condition, and in the case of nobles the con- 
fiscation of half of their worldly goods and relegation to an 
island ; but, if from their fault, the looinan or man shall have 
perished they are to undergo the highest sentence. 

This text is exceedingly obscure, and lends itself to 
several interpretations. In the first place, what does it 
mean by woman or man ? The first hypothesis that 
may be admitted is that the term man applied to an ani- 
mated fetus, which, from this fact, was morally con- 
sidered as a living individual, and from this it becomes 
evident that the word woman was used to designate the 
mother of the said fetus ; or else the woman corresponds 
to the abortive drink and man to the love philter. 

Without wishing to endeavor to settle this question it 
would appear that the last hypothesis is the most 
plausible. Now, in point of fact, the article includes 
two different things, namely the love philter and the 
abortive drink. For the latter there can be no doubt, 
because it was destined for women. As to the second it 
was used in the masculine sex as well as in the female, 
but the construction of the article very probably only 
considered those cases in which it was administered to a 
male subject. There is to be found successively those 
who administer an abortive drink, or a love philter and 
further on, "if from this fact the woman or man shall 
have perished "; these terms appear to well establish a 
near relationship between the abortive drink and the 
female on the one hand and between the love philter and 
man on the other. However this may be I consider, 
with Jou.sse, that there was not, properly speaking, any 
special legislation applicable to these particular crimes. 
Those who employed them sulficiently maladroitly to 
bring about death were considered guilty of homicide 
and were punished as such. The sentence was consider- 
ably increased when malice aforethought was added to 
the administration of a love philter. In the great 
majority of cases the courts were rarely called upon to 
interfere because these philters rarely gave rise to death. 
Drinks given to produce sleep, or to cause sterile women 
to conceive were assimilated to philters. 



Tlie Lepers of Poena. — The Mission to Lepers has 
secured in gifts and promises £825 towards the £1,000 
required for its new asylum for the lepers of Poona 
(Bombay Presidency). A further sum of £175 would 
enable it to claim the grant promised by the authorities 
and to make proper provision for the many homeless 
outcasts of the district. 



72 A.MERICAN MbDICINEJ 



DIGEST OF MEDICAL LITERATURE 



rjANUARY 13, 190« 
LVOL. XI, No. 2 



DIGEST OF MEDICAL LITERATURE 



CLINICAL MEDICINE. 

David Riesman A. O. J. Kelly 

nobman b. gwtn bernard kohn 

Helen Mukpht 



THE QUESTION OF " FOURTH DISEASE " AND 
"FIFTH DISEASE." 

A CRITICAL SUMMARY. 

BY 

BERNARD KOHN, M.S., M.D. 

The history of the exanthematous diseases is one of 
successive differentiation. Measles was confounded with 
scarlet fever, and even with smallpox, as late as the middle 
of the eighteenth century, while rubella is a quite modern 
acquisition. In fact, so recent a work as " Nothnagel's 
System " devotes several pages to a discussion as to the 
identity and individuality of this latter disease. Its 
standing, however, has by this time been quite definitely 
accepted by the medical world, but the argument has 
been turned toward a further differentiation. 

It seems that the term rubella has been covering at 
least two, and perhaps three separate diseases. Although 
the literature on the exanthems had contained low 
mutterings of the approaching storm for many years, the 
standard of revolt in the cause of the " Fourth Disease " 
was first raised by Clement Dukes (The Lancet, July 14, 
1900). His claims were soon advocated by several 
authorities (Johnstone, Broadbent, Homer, Kidd, 
Weaver, Ashby, and others), while others (Millard, 
Washbourn, Rutter, Poynton, Williams, Ker, Griffith) 
denied the individuality of the new disease. The previous 
descriptions of rubella have usually recognized the 
existence of two forms — the morbillous and the scar- 
latinous. Some of the opponents of Dukes regard the 
"Fourth Disease" as a scarlatiniform rubella, while 
others believe it to be a mixed infection ; still others a 
mild scarlatina, a desquamative scarlatiniform eryth- 
ema, etc. 

The "Fourth Disease" theory has received little 
encouragement in this country, but recently its cause 
has been taken up on the continent of Europe and has 
been rather strongly advocated. J. von B6kay (Deutsche 
medicinische Wochenschrift, 1904, No. 43, p. 1561) calls 
attention to the fact that Filatow in 1885 described a con- 
dition identical with that of Dukes under the name 
"rubeola scarlatinosa," he believing it to be a form of 
rubella. B6kay, therefore, first proposes the term 
" Filatow-Dukes' Disease." J. Ruhemann (Deutsche 
medicinische Wochenschrift, 1905, No. 3, p. 105) reports 
a small epidemic that he observed in 1898 before Dukes' 
paper appeared, and noted as "rubeola scarlatiniformis." 
Some of the cases had previously had scarlet fever, other- 
wise he might have made the diagnosis of mild scar- 
latina, so closely did the eruption resemble that disease. 
L. Cheinisse (La Semaine M6dicale, 1905, No. 13, p. 145), 
after reviewing the literature in a most complete manner, 
decides emphatically in favor of the fourth disease and 
proposes the name "epidemic pseudoscarlatina." The 
latest word on the question has been said by O. Unruh 



(Deutsche Archiv. fiir klinische Medicine, Bd. Ixxxv, 
p. 1). He calls attention to the numerous cases observed 
by himself and many other physicians, which cannot be 
accurately brought under the head of either scarlatina, 
measles or rubella. The facts that these cases often 
occur in characteristic epidemics and always exhibit the 
same symptoms and course, that an attack may occur in 
a child who has already had scarlet fever and rubella, 
and that it does not protect from future attacks of these 
two diseases in those who have never had them, all tend 
to prove that we have to deal here with a separate dis- 
ease entity. 

The characteristics of the exanthem, as observed and 
described by Unruh, Ruhemann, B6kay, and others, 
correspond quite closely with the original description 
of Dukes. It occurs almost exclusively in school chil- 
dren. The period of incubation seems to be about two 
weeks, but is put down at 9 to 21 days. It is not as 
contagious as scarlet fever or measles. In most cases 
there are no prodromes, although these may be present 
in severe cases. The rash consists of a closely punctated, 
very slightly raised erythematous blush, the color of 
which resembles that of scarlet fever, but may be a little 
more brownish. It appears first on the face, and in a 
few hours spreads over the entire body. The lips and 
nose are usually left free, and the eruption may appear 
patchy on the rest of the face, but the body and extrem- 
ities are more uniformly covered. The rash fades rap- 
idly, often in 24 to 36 hours, and is immediately followed 
by a slight desquamation in the form of minute scales 
(never in lamellas), which usually lasts at most two 
weeks. There is usually some injection of the pharynx 
and conjunctivas, but Koplik's spots and the strawberry 
tongue are never observed. Moderate fever of short 
duration is invariable, but the subjective symptoms are 
slight or entirely wanting. There may be very slight 
glandular enlargement, but it never reaches the propor- 
tions characteristic of scarlet fever, and especially of 
rubella. Complications or sequels have never been 
observed. 

This symptom-complex differs from the typic de- 
scriptions of rubella in too many points to be regarded 
as a mere variety of that disease. This is especially 
true in view of the fact that the other exanthematous 
diseases always present a more or less uniform picture. 
So, although the idea of a fourth disease did not find 
much favor at first, this more recent accumulation of 
evidence seems to establish its independent status. If 
Filatow-Dukes' disease is finally accepted as a separate 
entity, it will probably include those cases which were 
formerly classified as a scarlatinous form of rubella, 
which latter disease will then embrace only the morbil- 
lous form. Of course a definite settlement of the ques- 
tion can only be obtained from a more accurate knowl- 
edge of the bacterial etiology of the exanthems. 

In the meantime, however, still another candidate 
for recognition has appeared in the field. A number of 
authorities have independently described with remark- 
able unanimity of details a fifth exanthematous condi- 
tion, which has heretofore been included in that heterog- 
enous symptom-complex, rubella. This " Fifth Dis- 
ease" is fathered by Escherich, and first described under 



January 13, 19061 
VOL. XI, No. 2 J 



DIGEST OF MEDICAL LITERATURE 



[American Medicine 73 



the name of " local rubella " by his pupils, A. Tschainer 
(Jahrbuch fiirKinderheilkunde, 1889, xxix, No. 3), and 
L. Gumplowicz (Ibid., 1891, xxxii. No. 3). Further 
observations are recorded by Escherich's assistant, A. 
Schmid (Wiener klinische Wochenschrift, November 23, 
1899), by Sticker (Zeitschrift fiir praktische Aerzte, 
June 1, 1899) under the name " erythema infectiosum," 
by L. Feilchenfeld (Deutsche medicinische Wochen- 
schrift, August 14, 1902), under the name "erythema 
simplex marginatum," and by other observers. Plachte 
(Berliner klinische Wochenschrift, February 29, 1904) 
calls it " megalerythema epidemicum," which term is 
also adopted by L. Cheinisse in a critical review (La 
Semaine M6dicale, May 3, 1905). The only notice 
accorded this condition in America is in a paper by 
H. L. K. Shaw (American Journal ' of the Medical 
Sciences, January, 1905), who gives it an independent 
status quite distinct from both rubella and Dukes' fourth 
disease. He says that other exantheiris afford no im- 
munity from "erythema infectiosum," and no out- 
break of measles or rubella follows exposure to its con- 
tagion. 

The disease always occurs in epidemic form, is most 
frequently associated with an epidemic of measles or 
rubella, and usually attacks children between 4 and 12. 
The period of incubation varies from 6 to 14 days, but is 
never as long as that of rubella. The eruption usually 
announces itself without prodromes, and appears first 
upon the face, especially on the cheeks. The skin be- 
comes the seat of a rose-red efHorescence, which is hot to 
the touch and is raised above the surrounding surface. 
There are absolutely no subjective sensations of heat, 
pain, or itching. The eruption is usually confluent upon 
the cheeks, is sharply demarcated by an irregular border, 
and usually spares the nose, lips, and chin. The appear- 
ance is very much like that of erysipelas. The funda- 
mental elements of the eruption are maculopapules. In 
24 to 48 hours it begins to fade from the center toward 
the periphery, and at the same time an analogous erup- 
tion appears on the extremities. Here the rash is more 
apt to be in the form of patches of varying size, giving 
more of a morbillous appearance. The extensor surfaces 
are especially affected and the eruption progresses from 
the proximal to the distal end of each extremity. As 
the patches fade in the center, the skin may assume a 
marbled appearance. The eruption almost invariably 
spares the trunk altogether. The mucous membranes are 
never affected, the scarlatinal tongue never develops, the 
lymphatics are not enlarged, and there is seldom any 
fever. Subjective symptoms are usually wanting. The 
total duration of the affection is 6 to 10 days. 

Here is a condition which is at greater variance than 
iB Dukes' disease with the other exanthems, and the 
same arguments that apply in the former ease are also 
brought forward hereto give this " Fifth Disease" an 
Independent status. The evidence is still too scanty 
upon which to base a positive conclusion, but the opinion 
of those prominent pediatrists who have already de- 
B<»ibed and accepted the disease is not to be regarded 
lightly. It is to be hoped that further observations in 
this country will help to solve the problem, both of the 
fourth and of the fifth disease. 



DISEASES OP THE LiUNGS. 

Bacteremia in Pulmonary Tuberculosis. — Pre- 
vious investigations concerning the occurrence of bac- 
teremia in the septic stage of pulmonary tuberculosis 
give varying results. This may be due to poor technic 
in many cases, as the later experiments with improved 
methods usually have given negative results. G. Joch- 
mann (Deut. Archiv. fiir klin. Med., Bd. Ixxxiii, p. 558) 
has investigated this question in 40 cases of pulmonary 
tuberculosis, all of which were in advanced stages, 
mostly with cavities, and with high fever. In all cases 
the results were constantly negative, even in the agonal 
period. Nine of the patients died during the course of 
the observations, and their blood was examined post- 
mortem. Seven of them gave absolutely sterile blood, 
one case developed streptococci, and another developed 
streptococci with Staphylococcus pyogenes aureus. The 
author concludes that bacteremia in pulmonary tubercu- 
losis is a very rare occurrence ; streptococci may occasion- 
ally be found, but the finding of staphylococci intra vitam 
is to be regarded with scepticism. Where organisms are 
found in the blood after death, their entrance must have 
occurred in the agonal period. A postmortal entrance 
probably cannot occur, as is shown by the author's 
experiments. He, therefore, maintains that the fever 
of progressive pulmonary tuberculosis is not caused by a 
bacteremia, but the possibility of a toxemia cannot be 
denied, [b.k.] 

Tlie Cause of Pulsations iu Empyema. — W. J. 
Calvert (American Journal of the Medical Sciences, 
November, 1905) says the requirements of pulsation are 
a firmly fixed pulsating organ ; contact of the pleural 
wall with this pulsating organ ; distention of the pleural 
sac with fluid, air, or solid material, and collapsed con- 
dition of the lung. The first is fulfilled by the thoracic 
aorta, the second by the normal relation of pleural wall 
to the thoracic aorta, the third by the presence of fluid, 
pus, or a combination of these with air in the pleural 
cavity, the fourth by the collapsed lung in pleurisy and 
empyema. In the normal thorax the pulsations of the 
aorta are absorbed by the easily compressible lung tis- 
sues, consequently are not transmitted. The impulse of 
the aorta transmitted to the pleural effusion will cause 
pulsation of the intercostal spaces. It follows from this 
that in pleural effusions pulsation is not a positive sign 
of pus. [A.G.E.] 

Acute Pericarditis Complicating Acute Lobar 
Pneumonia. — J. A. Chatard (Johns Hopkins Hospital 
Bulletin, October, 1905) considers this a most serious 
complication, occurring more especially in young adults, 
frequently insidious, latent, and often not recognized 
during life. It appears to arise as frequently by a metas- 
tatic process as by direct extension. Treatment is very 
unsatisfactory and often unavailing, except when fluid 
is present, in which case it is more surgical than med- 
ical. A careful watch shoUld be kept on the heart, as 
urgent treatment in the early stages may materially 
reduce a high mortality, [ii.m.] 

The Influenza Bacillus in Bronchiectasis. — T. 
R. Boggs (American Journal of the Medical Sciences, 
November, 1905) says with the exception of the investi- 
gations of Lord, the relationship of B. influenza to 
chronic pulmonary disease has received but little atten- 
tion in this country. He presents notes of six cases 
studied in the Johns Hopkins Hospital and reaches these 
conclusions : (1) The influenza bacillus is probably capa- 
ble of producing extensive pathologic changes in the 
lungs, leading at times to bronchiectasis. The organism 
may be a secondary invader or associated with other 
bacteria ; the latter may be the preponderant factor. In 
our small series there was no clinical difference deter- 
minable between the pure influenza infections and the 
mixed noninfluenza cases. (2) The very close clinical 
resemblance of these cases of bronchiectasis to some 
cases of chronic tuberculosis with cavity formation is 



74 Amkbican MedicinkJ 



DIGE8T OF MEDICAL LITERATURE 



CjAHnARY 13, 1906 
Vol. XI, No. 2 



important and may, in the absence of cultural investi- 
gations, lead to wrong diagnoses. Pliysical signs alone, 
therefore, cannot be relied upon for a positive diagnosis 
of tuberculosis. (3) Care should be taken to prevent the 
possible infection of others from these chronic cases hav- 
ing influenza bacilli in the sputum, as the organisms may 
not have lost their pathogenicity by a continued growth 
in these old infections, [a.c.e.] 

Dangers of Forced Feeding in Tuberculosis. — 
F. Mouisset (Lyon M6dical, Oct. 29, 1905) says forced 
feeding is adopted in tuberculosis for the purpose of hav- 
ing the patient put on flesh. But if the feeding be badly 
regulated, digestive disturbances and their consequences 
will offset the good eflfects otherwise gained. A rapid 
gain in weight is to be avoided, and a weekly gain of 
250 gm. (J lb.) should ordinarily be sufticient. Among 
the immediate dangers of forced feeding are hyperchlor- 
hydria, hyperacidity from secondary fermentations, and 
dyspepsia. Diarrhea may be produced, when the intes- 
tines receive food from the stomach that is poorly pre- 
pared for digestion. A mucomembranous colitis is also 
among the possibilities, while a condition of autointoxi- 
cation may produce the picture of neurasthenia. Albu- 
minuria, hepatic disturbances, and cutaneous complica- 
tions are also among the results of suralimentation. 
Among the more remote effects of forced feeding, the 
most serious is the production of pulmonary congestive 
crises, which may result in a diffuse bronchitis, asthma, 
hemoptysis, or the lighting up of old tuberculous lesions. 
In order to obtain the best results from feeding in tuber- 
culosis, there should be regularity in the composition of 
the meals, the diff"erent dishes should be proportioned 
conveniently, and those articles of food should be chosen 
that give the greatest nourishment with the least bulk. 
The proteids and carbohydrates are of the most value. 
Eggs and milk in moderation are valuable, but a too 
great number of the former will overtax digestion, while 
large quantities of milk offer the disadvantage of too 
much liquid. Raw meat affords a very rich food, and 
may supplant cooked meat at times. In prescribing a 
diet for the tuberculous patient, the physician should 
examine the gastrointestinal tract as carefully as he does 
the lungs, and should adapt the food to the digestive 
powers of those organs. [n.K.] 

Endocarditis in Tuberculosis. — H. T. Marshall 
(Johns Hopkins Hospital Bulletin, September, 1905) 
reviews the literature of the subject and reports the 
cases occurring in the pathologic and medical records of 
Johns Hopkins Hospital. From the review it is evi- 
dent that it is not easy to prove that any given endo- 
cardial vegetation is produced by the tubercle bacillus, 
as this must be demonstrated not on the surface, but in 
the depth of the vegetation, and thus stained sections 
are of more value than cultures or inoculations, as the 
position in which the bacteria occur is more certainly 
determined by this method. The elastic tissue stain 
must be used to prove that the process is above the elas- 
tica, that is, in the endocardium, not the myocardium. 
Such complete proof has been furnished in a few cases, and 
some writers, particularly the French, hold that the 
endocarditis in tuberculosis is not due to the direct 
activity of the bacilli in the vegetation, but to a toxin 
elaborated by the bacilli elsewhere and carried by the 
circulation, producing a toxic endocarditis. It seems 
hardly probable that the vegetations arise from toxins 
alone. The bacilli in a vegetation may be missed for sev- 
eral reasons. A few may furnish a focus on which a large 
thrombus develops, and would be found only in serial 
sections. The bacteria may be of low vitality and die 
out in the vegetation, or they may die as the result of 
protective substances formed in the circulation, and 
they are in a favorable position for attack by phagocytes. 
The cases reported cover those of endocarditis preceding 
tuberculosis, miliary tuberculosis in the endocardium, 
and nontuberculous endocarditis in tuberculosis, [h.m.] 



GYNECOLOGY AlTD OBSTETRICS. 

WlLMER KKUSEN 



THE TREATMENT OF UTERINE RETRODISPLACE- 
MENTS. 

A DIGEST OF RECENT PUBLICATIONS. 



WILMER KRUSEN, M.D. 

The treatment of uterine retrodisplacements may be 
divided into palliative and surgical. The palliative 
treatment consists of the use of tampons and pessaries. 
Hirst (Textbook of Diseases of Women, p. 279) con- 
siders that the reaction against the use of pessaries 
has gone too far; that in some cases the ut«rus may 
be maintained in a good position indefinitely by a 
pessary and the patient be made perfectly comfortable ; 
and if the patient elects this method of treatment after a 
full knowledge of the facts and of the possibility of a 
permanent cure by operative treatment, she has a perfect 
right to choose her own course. 

Ashton (Practice of Gynecology, 1905, p. 353) says 
that the use of a pessary may in some cases effect a 
symptomatic cure, but the displacement will recur as 
soon as the instrument is discarded ; and it should, there- 
fore, be employed only when the patient refuses opera- 
tive measures. Pryor (Gynecology, 1903), in discussing 
the use of the pessary, says that in cases of incomplete 
retroposition, which are readily replaced and in which 
no laceration of the soft parts exists, a well-fitted pessary 
will relieve. A pessary should never be introduced 
when any inflammation of the adnexa exists or the 
uterus is fixed ; and one should never be employed when 
the displacement is due to endometritis until the latter 
has been cured. He believes there is too great a 
tendency in the profession to perform oi)erations for 
retrodisplacements without first employing less severe 
methods. Twenty years ago Vedeler published a review 
of 3,200 cases of retroflexion. At that time it was con- 
sidered absolutely abnormal, while now it is considered 
only relatively so. It may exist without symptoms, 
although these are liable to develop at any time. In his 
most recent paper (Nordiskt mediciniskt Archiv, xxxvii; 
Surgery, No. 4, [Journal of American Medical Asso- 
ciation] ) he says that he regards fixation of the uterus as 
contrary to the laws of anatomy and physiology. Pes- 
sary treatment conflicts with modern ideas of asepsis 
and infection. The diseased retroflexed uterus, he 
thinks, should be treated according to the same prin- 
ciples as the diseased anteflexed organ. He found ante- 
flexion in 64^ of 7,200 women, retroversion in 20;*, 
retroflexion in 9^, and anteversion in 7fc. He ob- 
served in 62 cases the spontaneous transformation 
of retroflexion into anteflexion, without morbid 
changes in the uterus. McNaughton-Jones (British 
Gynecological Journal, May 1, 1904), in a paper before 
the British Gynecological Society, states that in all forms 
of displacement in which its employment is clearly indi- 
cated a pessary generally gives material relief. He 
briefly summarizes the pathologic conditions which con- 
traindicate the use of any pessary as follows: 1. Dis- 



J ANUAHY 13, 1906T 

Vol. XI, No. 2 J 



DIGEST OF MEDICAL LITERATURE 



[Amkrican Mkdicinf 75 



placements which are associated with inilammatory 
states of the endometrium until such endometritis be 
cured. 2. Those which are complicated by adhesions, 
rendering restoration of the uterus to its normal position 
impracticable. 3. Those associated with adnexal tumors 
and inflammatory conditions of the ovaries and tubes. 
4. Those complicated by other than adnexal tumors in 
the pouch of Douglas, such as enlarged, sensitive, and 
prolapsed ovary, cysts of the ovary or mesosalpinx, pus 
cysts of tube or ovary, ectopic sacs, pedunculate myomas, 
solid tumors of the ovary or fallopian tube. 5. All cases 
in which, after reasonable trial of a pessary and pallia- 
tive treatment of the displacement, the prolonged use of 
a pessary is necessitated, inasmuch as without the latter 
the displacement recurs, and when, even with the pes- 
sary in situ, the uterus cannot be kept in the normal 
position. This summary practically represents the 
present status of gynecologic opinion in regard to this 
instrument, that it has a definite place when properly 
fitted as a palliative measure in the treatment of retro- 
displacements. 

The pessaries usually employed by American gyne- 
cologists are the various modifications of the Hodge pes- 
sary, which consists of a posterior bar, with converging 
side bars, which are united by a shorter bar anteriorly. 
Laterally, the pessary has the shape of the letter S. In 
its modifications by Thomas and Munde, the posterior 
bar is thickened, thus making a larger mass in the poste- 
rior vaginal fornix. 

The tampon may be employed temporarily to main- 
tain a retrodisplaeed uterus in its proper position, or 
when medicaments are to be introduced. According 
to Montgomery (Practical Gynecology, 1903), the best 
tampon is composed of a combination of gauze and 
cotton or of lamb's wool. 

In discussing the surgical treatment for these mal-' 
positions, one finds the decision is difficult as to the 
proper operation to select in the face of such contradic- 
tory statements from eminent operators. Statistics will 
prove anything. Good results have been obtained from 
many procedures, while bad results have attended all 
operations in the hands of unskilful operators. Careful 
discrimination and excellent surgical judgment are neces- 
sary in the selection of the operation best suited to the 
individual case. Lucy Walte (Journal of American Med- 
ical Association, Feb. 11, 1905) pertinently observes that 
" it is time to take more frequent and accurate invento- 
ries of our work with the view to discarding antiquated 
methods and retaining those which have proved success- 
ftal and beneficial." At least 50 different methods 
have been proposed, several years of operating have 
passed, and the testimony in regard to these operations 
is now coming in, making such inventories practicable. 

These operative procedures may be divided into four 
distinct classes : 1. Extraperitoneal methods of shorten- 
ing the round ligaments. 2. Intraperitoneal methods of 
shortening the round ligaments. 3. The operations for 
abdominal suspension. 4. Operations through the 
vagina. 

The old fear of the peritoneum formerly caused sur- 
geons to avoid opening into the abdominal cavity ; but 
[the possibility of fixing the retroflexed uterus in such a 



way that its fundus comes in contact with the anterior 
abdominal wall, gave rise, many years ago, to the idea 
of direct anterior fixation without laparotomy. Accord- 
ing to Emmet, Marion Sims first conceived this idea in 
1859 and constructed a special hollow needle to pass a 
silver suture with this object, but having one day begun 
the operation he had not the audacity to finish it. 
Caneva, more than 20 years afterward, proposed abdom- 
inal hysteropexy by piercing the serous membrane 
through a small exposed surface but does not seem to 
have performed it. But all such blind procedures as 
these have been abandoned since the present perfected 
operations of suspension have been developed. One of 
the first premeditated operations for the retrodisplace- 
ment of the uterus was performed by Koebele in 1869 
who, in a difficult case of retroflexion which had caused 
symptoms of chronic intestinal obstruction, incised the 
abdominal wall, brought the uterus forward, removed a 
healthy ovary, and sutured the pedicle to the lower 
border of the wound. 

According to Pozzi the plan of sustaining the uterus 
by shortening the round ligaments originated with 
Alquie, of Montpelier, France, while two English sur- 
geons, Adams and Alexander, reinvented the operation 
and performed it about the same time. This operation, 
which has become classic under the name of Alexander, 
consists in shortening the round ligaments by pulling 
them out of the inguinal canal and after cutting off the sur- 
plus ligament, stitching the free ends into the external 
wound. There are a few modifications of this procedure 
worthy of mention. First, the biinguinal operation 
suggested by Goldspohn (Journal of American Medical 
Association, Nov. 18, 1905), of Chicago, who performed a 
biinguinal celiotomy using the Bassini hernia technic, 
enclosing the wounds with the anchorage of the round 
ligaments to Poupart's ligament. This operation per- 
mits of intraperitoneal investigation and manipulation 
and, according to Goldspohn, is supported by certain 
stern anatomic facts : 1. The round ligaments of the 
uterus are the only structures continuous with it that, as 
a part of it, are composed sufficiently of nonstriated 
muscular fiber to undergo growth with it during gesta- 
tion, and also involution after labor. 2. The round 
ligaments taper from within outward, so much so that 
their uterine origins are at least six times as strong as 
they are at their extraperitoneal, but intraabdominal, 
portions, which compose their most vulnerable points. 
3. These weaker parts that call for reinforcement or 
elimination, however, are readily accessible through the 
inguinal canals from without, and not advantageously 
from any abdominal or vaginal incision. While he 
advocates his own procedure, Goldspohn believes that 
the intramural transplantation of the round ligament is 
far preferable to those operations that shorten them by 
doubling up the thick and accessible ends of the struc- 
tures, while leaving the outer feeble and inaccesible por- 
tions as weak and as liable to stretch as before. 

Edebohls splits the entire length of the inguinal 
canals, draws the ligament out at the internal ring, and 
closes the wound as in the Bassini operation. Martin, 
of Chicago, and Duret, of Lille, do not use sutures, but 
pass a pair of dressing forceps beneath the skin and sub- 



76 



"VSIKRICAN MedICINB] 



DIGEST OF MEDICAL LITERATURE 



C January 13, 190B 
Vol. XI, No. 2 



cutaneous tissue, from one wound to the other, draw the 
ligaments through, tie the two ends together in a linot, 
and close the tissues over the union. Martin considers 
this operation superior to all others because it insures a 
uniform shortening of the ligaments, with a permanent 
and strong fixation, without the necessity of placing any 
sutures, either temporary or permanent, thus eliminat- 
ing the possibility of fistulous tracts being formed because 
of infected sutures. 

On the other hand, the disadvantages that have been 
urged against the Alexander operation and its modifica- 
tions are, that two incisions are necessary ; that the pro- 
cedure is limited in its application unless a free intra- 
peritoneal incision is made over the weakened portion 
of the abdominal walls ; that the round ligaments are so 
attenuated as to be of little use in maintaining the organ ; 
and that in cases of infection the involved ligament may 
slip back and carry infection beneath the peritoneum. 

The second class of operations are those for the intra- 
abdominal shortening of the round ligaments. In this 
-operation the round ligaments are shortened within the 
peritoneal cavity by making a median incision. This 
permits the uterus and appendages to be examined and 
treated, if necessary ; while existing adhesions can be 
broken up and the round ligaments shortened by folding 
them upon themselves, as suggested by Wylie, Ruggi, 
Bode, and Mann ; or by suturing them in front of the 
uterus, as suggested by Polk and Dudley. Bies, of Chi- 
cago, cuts a slit through the anterior surface of the 
fundus, through which a loop of the round ligament is 
carried and sutured to a corresponding loop from the 
opposite side. Menge (Centralblatt fur Gynakologie, 
No. 24, 1904), of Leipzig, describes a method of ven- 
tral fixation which consists in stitching a sling, made 
by the intraperitoneal shortening of the round 
ligaments, to the abdominal wall at the level of the 
insertion of the ligaments into the uterus, using catgut 
only for the fixation sutures. Webster picks up a loop 
of the round ligament and carries it through the broad 
ligament beneath the oviduct and secures it to the poste- 
rior surface of the uterus. This procedure has been 
modified by Baldy, of Philadelphia, who ligates the 
uterine end of the round ligaments, incises them exter- 
nal to the ligatures, and carries the free ends, instead of 
the loops, through the broad ligaments and fastens them 
to the posterior surface of the uterus. * 

Of the operations recently described, one of the most 
important is that designated by its author, Gillam 
(Practical Gynecology, 1903), of Columbus, Ohio, as 
the round ligament ventrosuspension of the uterus.- 
In this procedure the usual median incision is em- 
ployed and a perforating forceps is passed^ obliquely 
through the fascia, muscle, and peritoneum of the 
abdominal wall, entering about half an inch from the 
edge of the incision and emerging on the peritoneum 
an inch from the edge of the incision. This forceps 
grasps a ligature which has been previously passed 
under the round ligament about an inch and a half from 
the uterus. The forceps is then withdrawn, bringing 
with it the thread and ligament which is sutured by a 
catgut suture to the fascia of the abdominal wall. Ac- 
cording to Gillam, the prime requisites of an operative 



device for retaining the uterus in normal position are, 
that it is one that will utilize the natural supports of the 
organ ; that will insure a certain amount of mobility ; 
that will adapt itself to the various functions of the uterus 
— pregnancy and parturition ; that will be la.sting in its 
results and withal easy of execution. This procedure 
seems to fulfil in a marked degree these requirements. 

Abdominal Operations. — Suspension of the uterus, ven- 
trofixation, gastrohysteropexy, gastrohysterorrhaphy, 
and gastrohysterosynaphy, are synonymous termsapplied 
to a number of similar abdominal operations, all of which 
are emjjloyed with a view of permanently overcoming ret- 
rodeviations of the uterus by the formation of an artificial 
ligament, which holds the fundus in an anterior posi- 
tion. Olshausen (Zentralblatt fiir Gynakologie, No. 43, 
1886), of Berlin, was the first to publish a paper upon 
this subject, while a few months later Kelly (Opera- 
tive Gynecology, 1898), of Baltimore, published his 
paper entitled " Hysterorrhaphy." This operation 
consists of an incision in the median line, through 
which the uterus is exposed, and the fundus sutured 
to the parietal peritoneum at the lower angle of the 
wound. This procedure has been extensively used by 
many operators for the radical cure of retrodisplace- 
ments of the uterus. Beyea (University of Penna. 
Medical Bulletin, Nov., 1904) reports a statistic study 
of 465 cases of ventrosuspension of the uterus, and 
states that it has always proved an efticient operation, 
has never been complicated, nor produced abnormal ges- 
tation, nor complicated labor. So far as he could ascer- 
tain, of 270 women from whom replies were received, 
163 were married, and of these 41 had been pregnant 
since the operation. In none of the labors was there 
any complication that could be attributed to the opera- 
tion. Weindler (Monatsschrift fiir Geb. und Gyn., 
June, 1905) sums up the results of the operations done 
by Leopold from 1896 to 1903, 51 cases, and gives 
the final result of all the cases that could be followed up 
and reexamined ; and, from his studies, is satisfied that 
this is the best operation for the treatment of retro- 
flexions of the uterus. Guerard (Monatsschrift fur 
G«b. und Gyn., Bd. xix, S. 229), of Dusseldorf, is con- 
vinced that no interference with labor need be expected 
from either ventral or vaginal fixation properly carried 
out. In 57 labors after ventral fixation there was no 
difficulty in 51 ; forceps were applied in 5. The fixation 
had been made supplementary to other operations in 49 
instances, and retroflexion had recurred in 2. In 41 
labors after vaginal fixation there was no difliculty in 
delivery in 39 ; the low forceps were used in 4 ; nor was 
there any disturbance during pregnancy. Retroflexion 
recurred in one instance. The fixation was made with 
two silk threads inserted somewhat below the mid- 
point, between the insertions of the tubes and that of 
the peritoneum, and the stitches were removed after 14 
days. There were 7 abortions after vaginal fixation. 
On the other hand, Milander, Bidone, Borland, and 
many others have reported unusually severe and com- 
plicated labors following ventral suspension. Lynch 
collected a large number of cases of serious dystocia, 
among them 21 cases of cesarean section and 10 of rup- 
tures of the uterus. 



JANUARY 13, 1906T 

Vol. XI, No. 2 J 



DIGEST OF MEDICAL LITERATURE 



fAMERICAN MEDICINH IT 



The objections that have been advanced against the 
operation of ventrosuspension are : 1 . That it substi- 
tutes a fixed, unnatural anteflexion for a retroflexion. 
2. That the attachment of the fundus of the uterus to 
the abdominal wall behind the symphysis pubis must 
interfere with the natural distention of the bladder and 
so excite dysuria. 3. That in event of pregnancy after 
the operation, the patient's life may be endangered 
by the inability of the uterus to develop naturally. 
Kelly (Operative Gynecology, 1898), in reply to these 
objections, states that in the first place the actual 
fixation to the abdominal wall lasts but a short 
time, and that bands of adhesion soon form which 
permit of a certain degree of mobility of the uterus ; 
second, that the irritability of the bladder usually is only 
temporary, as the female bladder usually expands 
physiologically lil^e saddle-bags, from side to side, and 
least in the anteroposterior direction ; third, that in a 
critical study of the effects of the operation upon subse- 
quent pregnancy, made by Noble, it was found that all 
the serious effects had been met with in the cases having 
broad adhesions between the uterus and the abdominal 
wall. Undoubtedly, the method of fixation that is 
employed has much to do with the complications which 
have arisen during pregnancy and parturition. 

Vaginal Operations. — One of the first vaginal proce- 
dures performed for the relief of retrodisplacement was 
that of Schucking, which consists in passing a curved 
instrument into the uterus from which a concealed 
needle was driven through the anterior vaginal fornix. 
This needle carried back a ligature which, when tied, 
fixed the uterus in a position of anteflexion. This opera- 
tion has long since been wisely abandoned because of the 
danger to the bladder and intestine. The operation of 
vaginal fixation devised by Duhrssen consists in making 
a vertical incision through the anterior vaginal wall in 
front of the cervix, pushing the bladder oflF until the 
peritoneum is reached. Without opening into the peri- 
toneal cavity, sutures are introduced, fastening the ante- 
rior wall of the uterus to the vagina. Mackenrodt modi- 
fled this procedure by opening through the peritoneum 
and introducing the sutures at a higher level, thus secur- 
ing the anterior wall to the vaginal incision. The opera- 
tion of hysterocysterorrhaphy, or attachment of the 
Uterus to the bladder, has also its advocates. This is 
done by opening the anterior culdesac per vaginam, 
denuding a small surface on the anterior wall of the 
uterus, and a corresponding surface on the posterior wall 
of the bladder, and uniting the two organs in this region 
by interrupted sutures. So many cases of dystocia have 
occurred after the operations of vaginal fixation that 
they have not found much favor among American gyne- 
cologists. Vineberg and Wertheim have devised opera- 
tions for shortening the round ligaments through the 
anterior vaginal incision, while Freund and Gottschalk 
make a posterior colpotomy by a vertical incision and 
shorten the uterosacral ligaments. Pryor (Gynecology, 
1903) advocated a transverse incision in the posterior 
vaginal fornix, through which he broke up adhesions, 
carried the uterus forward and packed gauze into the 
posterior culdesac ; then with a tampon he pressed the 
rrvix well upward and backward, the subsequent 



adhesions of the cervix in this position leading to a 
correction of the malposition. The cervix becomes 
anchored in this high and backward position, and the 
intraabdominal pressure, acting upon the body of the 
uterus, forces it forward. 

Space will not permit a further review of the litera- 
ture upon these mooted points, but from a careful study 
it seems that the general trend is toward the abandon- 
ment, by American operators at least, of the vaginal 
procedures and the employment of the ventrosuspension 
procedure only in those cases in which subsequent preg- 
nancy cannot possibly occur ; that those operations on 
the round ligaments which utilize the inner and stronger 
parts for sustaining the organ are steadily growing in 
favor; that with our perfected technic and ability to 
treat adhesions and diseases of the appendages more- 
readily, the median incision will supersede the biingui- 
nal methods. Every gynecologist who devises a modi- 
fication of a procedure naturally favors the child of his- 
inventive genius, and sometimes overestimates its value ; 
so that it is only by a calm and unbiased appreciation of 
the limitations of all these methods and the exercise of 
discriminating judgment that the best application may 
be made in the interest of the individual case. In con- 
clusion, it is interesting to note that the pessary is not 
regarded as an antiquated and obsolete instrument, but 
that many of our practical and experienced gynecologists 
have found a definite place for it in the treatment of 
mobile and uncomplicated retrodisplacements. 



INDEX OF LEADING ARTICLES. 

Journal of the American Medical Association,. 

Vol. xlvi. No. 1, January 6, 1906. 

" The Dietetic Treatment of Nephritis." F. C. Shat- 
TUC'K, Boston. See American Medicine, Vol. x. 
No. 9, p. 345. 

" Albuminuria in Nephritis and Bright's Disease." Al- 
fred Stengel, Philadelphia. See American Med- 
ioine, Vol. 10, No. 7, p. 260. 

"Cylindruria." jCharles P. Emerson, Baltimore^ 
See American Medicine, Vol. x, No. 8, p. 303. 

" A Study of Brain Infections with the Pneumococcus." 
E. E, Southard and C. W. Keene, Boston. 

" The Dumb-bell Intestinal Anastomo.sis. A Preliminary 
Report on a New Mechanical Device and a New 
Method for Either Intestinal Approximation or 
Anastomosis with the Stomach." JopephB. Bacon, 
Macomb, 111. 

" Rontgen Diagnosis of Diseases of the Lungs." G. E. 
Pfahler, Philadelphia. See American Medidne. 
Vol. x, No. 20, p. 809. 

" First Aid to the Injured : Its Importance to Railroads 
from a Humane and Economic Standpoint." Mar- 
cus H. Thomas, Huntington, Ind. 

"The Treatment of the Results of Infantile Paralysis." 
Prescott Le Breton, Buffalo, N. Y. 

" Disorders from Eyestrain." Ovidus Arthur Grif- 
fin, Ann Arbor, Mich. 

"An Analytic Study of Uremia, with Some General 
Conclusions in Regard to Its Causes and Treatment." 
Alfred C. Croftan, Chicago. 

" A Case of Traumatic Aneurysm of the Right Renal 
Artery, with a Review of the Literature." Penn- 
Gahkell Skillern, Jr., Philadelphia. 



78 



American Medicink] 



INDEX OF LEADING ARTICLES 



C January 13, 1908 
Vol. XI, No. 2 



Medical Record, Vol. 69, No. 1, January 6, 1906. 

"Rupture of the Esophagus Resulting from External 

Traumatism." Howard E. Lomax, Albany, N.Y. 
"Acute Yellow Atrophy of the Liver Following 

Eclampsia." L. T. Royster and Charles R. 

Gkandy, Norfolk, Va. 
"Selective Absorption by the Cell." William F, 

Waugh, Chicago, 
" Eyes and Ears that Might be Saved : An Appeal to 

the General Practitioner." Samuel S. Wallian, 

New York. 
" Nailing the Head of the Humerus for Fracture of the 

Surgical Neck, with Report of a Case." H. A. Hau- 

BOLD, New York. 
" Sutures and Their Preparation." W. H. Wattebs, 

Boston. 
" Radium, Its Known Medical Value." Myron Met- 

zenbaum, Cleveland, O. 

^ Boston Medical and Surgical Journal, Vol. cliv, 
No. 1, January 4, 1906. 

" The Physical Aspect of American Football." Edward 
H. Nichols and Homer B. Smith. See editorial 
pages this issue. 

"Fractures of the Superior Maxillary Bone Caused by 
Direct Blows Over the Malar Bone : a Method for 
the Treatment of Such Fractures." Howard A. 
LoTHROP, Boston. 

"Puerperal Septicemia." E. H. Stevens, Cambridge, 
Mass. 

New York Medical Journal, Vol. Ixxxiii, No. 1, 
January 6, 1906. 

" Axillary and Pectoral Cicatrics Following the Removal 
of the Breast, Axillary Glands, and Connective Tis- 
sue for Malignant or Other Diseases." John B. 
Murphy, Chicago. 

" Hand Protection in Rontgen Praxis." Henry G. 
PiFFARD, New York. 

" Professor F. Blochmann's Work on Accidental Vac- 
cination." George Dock, Ann Arbor, Mich. 

"Pathology and Diagnosis of Myocardial Inflammations 
and Degenerations." Judson Daland, Philadel- 
phia. 

" The Difl'erence in the Behavior of Dust from That of 
Bacteria in the Tonsillar Crypts." Jonathan 
Wright, New York. 

" Chronic Endotraehelitis : a New Method of Treatment 
with New Instruments." Daniel H. Craig, Bos- 
ton. 

"The Vicious Circle After Gastroenterostomy." John 
B. Deavek, Philadelphia. 

" Water as a Local Anesthetic." John A. Wyeth, 
New York. 

" The Strenuous Life of School Girls." William P. 
Northrup, New York. 

" Aphasia Hemiparesis and Hemianesthesia in Mi- 
graine." Smith Ely Jelliffe, New York. 

The Laucet, Vol. clxix. No. 4296, December 30, 1905. 

"The Medical Treatment of Uterine Fibroids and Its 

Limitations." Thomas Wilson. 
" A Case of Acute Hemorrhagic Pancreatitis." Harold 

V. MUNSTER. 

" A Consideration of the Cholera, Yellow Fever, and 
Plague Regulations and Aliens' Act, 1906, in Their 
Relation to the Prevention of the Spread of These 
Diseases." Duncan Forbes. 



" Four Cases of Hysterectomy." Skene Keith. 
"A Case of Melsena Neonatorum: Recovery." Ed- 
ward Foktrey Heap. 

British Medical Journal, No. 2318, December 30, 
1905. 

"A Preliminary Inquiry Into the Tonicity of the 
Muscle Fibers of the Heart." Jame.s Mackenzie. 

" Inebriety as a Physical Disease." H. W. Mann. 

"Some Toxic Effects of Aspirin." J. S. Dockray. 

"A Peculiar Form of Akromegaly, Possibly Resulting 
from Injury." J. C. Pkittie Perry. 

"Addison's Disease." William Tibbles. 

" The Parathyroids In Graves' Disease." S. G. Shat- 

T03K, 

"On the Pathogenic Ticks Concerned in the Distribution 

of Disease in Man." R. Newstead. 
" On the Ethics of a Prescription." G. A. Batchelob. 
" Notes on a Case of Pneumothorax." John McKie. 

Milnchener inedicinische Wochenschrift, Vol, 

ill. No. 52, December 26, 1905. 

" Treatment of Pelvic Inflammations by Hot Air." 

Jung, of Greifswald. 
"Tuberculin Treatment in Dispensary Practice and in 

Febrile Cases." Krause. 

" Brachialgia." Bbassert, Leipzig. 

"Acetone for Paraffin Embedding : a Simple and Rapid 
Method." Brunk, Posen. 

" Compression of the Urinary Organs by Tumors of the 

Adnexa." Nas.sauer. 
"Extension Stretcher." Hofmann, Karlsruhe. 
"A Case of Luxation of the Terminal Phalanx of the 

Middle Finger." Roemer. 
" Hebotomy." Bauereisen, Erlangen. 

Berliner klinische Wochenschrift, Vol. xlii, No. 
52, December 25, 1905. 

" Inflammations of the Pancreas." Th. Bbugsch and 

F. KOENIG. 

"Pancreatic Diseases in Diabetes." F. Hirschfeld. 

" Treatment and Prophylaxis of Scarlet Fever." Campe. 

" The Study of Nitrogenous Substances of the Urine, 
Insoluble in Alcohol." E. Salkowski. 

" Several New Questions in the Epidemiology of Ty- 
phoid Fever." Kutscher. 

Wiener klinische Wochenschrift, Vol. xviii, 
No. 51, December 21, 1905. 

" Indications for Appendicectomy in Pain in the Ileo- 
cecal Region." Hochenegg. 

" Metallic Radiations." Franz Steeintz, Graz. 

" The Usefulness of Stumps after Bunge's Amputation." 

F. Ranzi and F. v. Auffenberg, Vienna. 
"A Rare Case of Spontaneous Version in Transverse 

Position of the Fetus." K. Zigmund, Oberberg. 

Deutsche inedicinische Wochenschrift, Vol. 

xxxi. No. 52, December 28, 1905. 

" Treatment of Cardiac Neuroses." Th. Rumpf, Bonn. 
" Further Successes of the Serum Treatment in Scarlet 

Fever." B. Schick, Vienna. 
" The Influence of Chlorin on Calcium Utilization in the 

Nursling." A. Schuetz, Budapest. 
" Primary Lesions on the Eyelid with Demonstration of 

Spirochetes." Kowalwski, Berlin. 
" Invalid Insurance and Tuberculosis." M. Wagner, 

Berlin. 



American Medicine' 



David Riesman 
Aller G. Ellis 
M. B. Hartzeli. 
xorman b. gwyn 
Helen Murphy 



GEORGE M. GOULD, Editor 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Rush 
Bernard Kohn 
John W. Churchman 



G. C. C. HOWARD, Managing Editor 



COLLABORATORS 

A. O. J. Kelly 
WiLMER Krusen 
John Knott 
Lawrence Hendee 
A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. Rhein 
J. Coles Brick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pylk 
D. Bradbn Kyle 
Eugene Lindauer 
Alfred Gordon 



Published Weckiy at 1321 Walnut Street Philadelphia bt the American-Medicine Publishing Company 



Vol. XI, No. 3. 



JANUAKY 20, 1906. 



$5.00 Yearly. 



Cold air In tuberculosis is now being given the 
credit for the wonderful results in mountain resorts. It 
is almost an axiom that one winter in the Adirondaclts, 
for instance, does as much good as two summers. 
Patients, both here and in Europe, are kept out doors 
all the year round, even when the thermometer drops 
to 30° or 40° F., below zero, and the cold air of 
itself seems to cure in a manner which nothing else can 
accomplish. In some sanatoriums forced feeding is not 
practised in the incipient stages as it is not as beneficial 
as a merely good, generous, animal diet, and though 
hyperalimentation is a positive necessity in later stages, 
particularly if anj' emaciation has occurred, it is not a 
means of treating the early cases which have not 
suffered loss of weight. Sunshine is not essential — ex- 
cellent results may be obtained in climates where the 
sun is very rarely seen. Mere outdoor living seems to 
be the essential element, and yet there does not appear 
to be any doubt that quicker results are obtained in the 
cold season than in the summer. 

The Method of Curative Action. — Much thought 
has been expended upon this phenomenon and several 
explanations have been offered, none of which is satisfac- 
tory. It has been suggested that as such cold air is con- 
densed, a cubic inch of it contains more oxygen, but it 
te probably warmed and expanded long before it reaches 
the lungs, and the wonderful results in surgical tuber- 
culosis, as reported by Prof. Halsted,' in which the 
lungs are not involved, would point to some other reason 
for the cure. There is, then, some other specific eflfect, 
probably acting in a reflex manner through the nervous 
[System, possibly in the nature of toning up of all tissues. 
Figuratively speaking, the protoplasm is keyed up to a 
I higher pitch and is more energetic in overcoming bacte- 
Irial invasions. Certainly, cases cured under such condi- 
Itions are not as lasting as those cured at sea-level in 
jwarmer air, and, indeed, the loss of tone on leaving the 

' American Medicine, Dec. 2, 1906. 



mountains not infrequently brings on early relapses. 
Even advanced cases seem to be arrested by cold air, but 
progress under all other treatments. The matter is not 
only of great general interest, but, from its practical 
value, it should receive an early explanation. 

The cold-air treatment for infantile pneumonia 

is discussed in a vigorous manner by Dr. W. P. North- 
rup,' Professor of Pediatrics of Bellevue. The method 
is such a startling change from the orthodox treatment 
of past generations, and yet so in line with recently ac- 
quired knowledge in other directions, that it is time for 
the profession of medicine to call a halt and overhaul its 
stock opinions. If the child's temperature is 105° F., it 
certainly is illogical to make it higher by hot chest poul- 
tices, heavy coverings, crib in a corner of the room, 
steam kettle boiling, gas leaking into room, and every 
breath of fresh air carefully excluded. Yet this is just 
the course instinctively followed by every mother, who 
always associates pneumonia with cold and its cure with 
heat. Northrup details two desperate cases treated upon 
the opposite plan, and though he leaves but little doubt 
as to the perfect reasonableness of it all, it is to be con- 
fessed that it will be difficult to make the average mother 
carry out the treatment. A room temperature which 
compels the attendants to wear overcoats and furs does 
seem harsh, but if the results are explained there should 
be no complaint. Cyanosis disappears, the blood red- 
dens, restlessness diminishes, sleep comes on, the heart 
is stronger, the respiration is less labored, digestion is 
improved— and all from the cold air which bathes the 
little suffterer's face and enters its lungs. If such great 
good cau be accomplished by this simple means, surely 
an effort should be made to induce mothers to carry out 
the method in all such cases. 

The cold-air treatment in iineunionia of adults 

has also been tried with apparent benefit. It is said to 



' New York Medical Record, Feb. 18, 1905. 



80 Ahbbican MEDtcmiEl 



EDITORIAL COMMENT 



rjANUAKY 20, 1908 

LVOL. XI, No. 3 



reduce cyanosis, lessen the rate of respiration and pulse, 
steady the heart, lessen fever, and reduce the discomfort 
and pain. It also seems logical to keep the patient cool 
all the time, instead of reducing his temperature only 
periodically by sponge baths, or even tubbing. In 
northern winters the windows have been kept open in 
the sick room even when the thermometer was much 
below the freezing-point. The patients promptly com- 
plain if the windows are closed and the air becomes 
warm and stuffy. It is not mere fresh air and ventila- 
tion, but the coldness which is appreciated. Taken 
with the results of similar treatment in tuberculous infect 
tion, it seems that there is some special benefit derived 
from cold air in all pulmonary infections. Pneumonia 
is said to be very rare, or even unknown, in the Arctics, 
and yet Eskimos perish of this disease when brought 
south. In the cold parts of the northwest, pneumonia 
rarely appears in the bitterly cold winter months, but is 
more a disease of spring, and even summer. Dr. Charles 
E. Page,' of Boston, not only emphasizes the necessity 
of cold, fresh air in pneumonia, but also the benefit of 
cold applications to the chest — constant cold, not peri- 
odical. He has many caustic things to say of the oppo- 
site methods which appear to increase the dangerous 
symptoms. Perhaps we can detect a growing tendency 
to keep all fever patients in cold air whenevec prac- 
ticable. The Japanese seem to obtain good results by 
this method, for their hospital wards in cold weather 
are kept at a low temperature, which would be consid- 
ered brutal with us. 

Cold air for typhoid and all other infections is 

but a step further — not cool air but cold. If all these 
new ideas are to be carried out to their legitimate con- 
clusion, it is surely proper to immerse every patient in 
his normal cold atmosphere and not a tropic one. He 
can be properly covered, even if he is breathing air 
freezing cold, but to make him breathe hot air seems as 
illogical as to place trout in warm water. The Brand 
method of cooling typhoid patients is known to save 
several in every hundred, and its remarkably beneficial 
effect on the nervous system is said to be the main rea- 
son. A walk through a typhoid ward where cold baths 
are given, reveals so many bright, intelligent faces — so 
different from the stupor of typhoid curing itself— that 
one almost thinks it is a different disease. It seems to 
have the same tonic effect as cold in surgical tuberculosis, 
but it is in order to inquire why the patient cannot be 
kept in cold air to continue the effect, properly covered, 
of course, so that it merely bathes his face and head and 
upper air passages. Perhaps the cold air of mountainous 

' New York Medical Journal, December 23, 1905. 



regions is the reason why typhoid takes such a mild 
course that it was actually considered a different disease 
for so long a time. The whole matter is worth consider- 
ing in every other infection, if with no other therapeutic 
view than with the mere idea of placing the patient in 
the normal European atmosphere known to be good for 
his ancestors. 

Cold Atr for Healthy People The thought is 

naturally suggested that perhaps cold air has hygienic 
as well as therapeutic uses. Warm sleeping rooms are 
strictly modern inventions, and pneumonia as a serious 
menace to life is also a comparatively recent affair. It 
is time, then, to inquire if our over-warmed houses 
have any relation to the appalling increase in pneu- 
monia. Does not this continual tropic house warmth 
actually reduce the tone of the tissues and make them 
more susceptible to bacterial invasion ? Foreigners bit- 
terly complain of the heat of our houses, and Americans 
abroad have equal objections to the coldness of foreign 
houses — keenly suffering in a Parisian hotel for instance, 
which is perfectly comfortable to the native. In Japan 
it is the same, Americans apparently being unable to 
live in the paper houses of the natives, who are comfort- 
able even when huddled around a few coals of fire. 
Perhaps the types of men in northern Europe, through 
ages of exposure to cold, have actually developed a 
physique which is not only inured to cold, but actually 
functions better in cold air than in hot. They surely 
are healthy and strong now, and do not suffer in the 
least from the cold. We rather look upon hot weather 
as relaxing and destructive of vitality, and expect 
health with return of cold weather. Brook trout perish 
if the water they breathe is raised only a few degrees in 
temperature. There is enough in this matter to cause 
us to think about it a little. If so many cured tuber- 
culous patients are now sleeping in cold air every night 
and living in it in the daytime, too, as much as possible, 
perhaps the rest of us are only injuring ourselves by 
the opposite course. Only a few years ago the cold-air 
fiend, who slept with windows wide open in the coldest 
winter, was considered a crank. Perhaps he will prove 
to have been the only sensible one among us, and was 
merely imitating the ways of his ancestors who had 
practically no way of warming their houses. 

Osteopathy is defined and described in the Neto 
Ywk Independent, November 9, 1905, by its originator, 
A. T. Still, of Kirksville, Mo., who explains, at first 
hand, many things of considerable interest to the med- 
ical profession. This peculiar medical cult has existed 
about 25 years, and was apparently doomed to death by 



( 



JANUARY 20, 19061 

Vol. XI, No. 8 J 



EDITORIAL COMMENT 



^Amekican Medicinb 81 



inanition when it took on renewed life about 10 years 
ago, and has shown such phenomenal growth since 
then that it is the part of wisdom to examine into the 
reasons for its existence. From his own statements, it 
is evident that Still began his work by one of those 
curious bits of illogic "reasoning" which make up so 
much of the history of the world — which, indeed, have 
always had a tremendous influence upon the course of 
events — from the burning of witches to the vagaries of 
Mohammedan fanatics. He knew that the life of cells 
was dependent, among other things, upon the foods 
brought to them by the blood. This one true idea then 
became dominant and overpowered all others, and a.s 
soon as such a mental attitude was gained, the other 
steps were easy. There could be no other condition 
which kept cells alive, and deprivation of blood was 
the only cause of cell death — excessive heat, deprivation 
of heat, corrosives, toxins, traumatism, interference 
with nerve-supply, and all the thousand and one things 
which can cause death, were either forgotten entirely or 
were considered to be merely remote causes of obstruc- 
tion of the circulation, or followed it. Then came the 
conclusion, "an unobstructed, healthy flow of arterial 
blood is life" — a definition which is phenomenal among 
nil the thou.sands of attempts to define life — phenomenal, 
in that it proceeds from as clear an obsession as it is 
possible for psychology to furnish. 

The ob.sessiou in osteopathy thus became the 
center around which all subsequent thoughts arranged 
themselves in the eflfort to explain pathology on one 
principle. For instance, disease must be partial death 
due to partial blood obstruction. The mind then sought 
for mechanical causes of the obstruction, and the expla- 
nation hit upon involved the usual mental gymnastics 
familiar to all students of psychology — that is, it was 
not due directly to pressure on the vessels at all, but 
pressure upon the spinal nerves as they passed through 
the foramens of the spinal column. A slip or "disloca- 
tion" (now called subluxation) of a vertebra caused a 
pressure upon the bloodvessels supplying the cord, and 
also pressed upon the nerves carrying "all the vital 
impulses between the cord and the viscera"— that is, 
the blood is no longer life, but the cord is ; the vital 
impulses travel through the nerves and not in the blood. 
Tissues are not diseased by interference with their blood 
supply, but by interference with the vital impulses in 
the nerves. Life is now considered as something which 
passes out of the cord through the foramens — "through 
them went life." The next step was inevitable — "at 
these foramens we find the seat of 95^ or more of the 
lesions" — that is, these are mere mechanical causes of 
all diseases except the 5fc due to unknown or unmen- 



tioned causes. The pressure is thus trebly effective— it 
deprives the cord of part of its life through pressure on 
its bloodvessels ; this diminished life is further dammed 
back by pressure on the spinal nerves through which it 
flows, but how this affects the blood supply of the dis- 
eased organs is not explained. The name osteopathy is 
thus to emphasize the theory that bone pressure causes 
all diseases. 

The spread of osteopathy is the thing to discuss, 
as it is quite evident that the illogic and bizarre theory 
cannot be seriously considered, particularly as it states 
that postmortem examinations reveal the pressures and 
that relief of the pressure is curative. The matter is 
merely one of the thousands of illogic baseless theories 
recorded in the history of medicine ; it is the dogmatism 
which has always afflicted every science. The text- 
books written by osteopaths are so full of unproved and 
unprovable assertions that any discussion of them is not 
possible. It is really pathetic in this age, but why does 
it not die ? One reason for the success of the cult is no 
doubt due to the fact that the massage and joint move- 
ments are really beneficial, or perhaps even curative, in 
a certain percentage of chronic invalids who no doubt 
constitute the majority of its devotees. Suggestion also 
is probably responsible for improvement in the neurotic 
cases which flock to every new fad. Even frauds may 
have great success temporarily, but so far as known there 
is not the slightest hint of fraud in the origin of this 
curious dogma. The main reason for the spread of the 
delusion involves the same illogic conduct characteristic 
of it all. The textbooks truly assert that no one can 
practise their methods unless he is thoroughly grounded 
in anatomy, physiology, and pathologic histology, to 
which we must add physics, chemistry, psychology, and 
all the branches of a liberal medical education, matters 
of several years of instructioi^ Nevertheless the grad- 
uates are turned out without the very instruction which 
is claimed to be essential. Hence, ignorant men, wholly 
lacking the first essentials for the practice of osteopathy, 
are given diplomas certifying that they are competent. 

The death of osteopathy can be safely predicted, 
and there is nothing to worry about. It will cure itself, 
for no system can stand if its professors are so ignorant. 
If they become learned they will not be osteopaths. No 
doubt many of them have been duped into taking up 
the alleged study and will drop it in time as they learn 
better ; those who cannot make a living at it will, of 
course, drop out, and the quacks who see in it a new 
field will work it as long as money can be squeezed out 
of a gullible public in this easy way. The licensing of 
osteopaths should not worry the public nor the regular 



82 Amkkioan Medicine] 



EDITORIAL COMMENT 



C January 20, 1906 
Vol. XI, No. 8 



medical profession. If they can pass an examination in 
the things which they declare essential to a knowledge 
of the cult, we should not object ; and the public must 
insist upon such knowledge to prevent injurious massage 
by ignorant pretenders. No man will spend the time 
necessary for such learning and not be convinced that 
he must know more. So it is proper for our legislators 
to insist upon these men passing a regular examination, 
and when once that is demanded, the delusion will fade 
and finally disappear to join the hosts of departed fads. 
It will last some years yet, probably many years, but all 
the people can't be fooled all the time. The pathetic 
side of the origin of the delusion is the part of the 
matter which has been so strangely overlooked. As a 
subject for psychologic study, it is of considerable scien- 
tific interest. A systematized delusion is defended in 
just the way this theory is explained. 

The lessons to be learned from osteopathy are 

quite evident, and are the same old lessons learned from 
every other similar movement. Of course there is the 
chance for ignorant but honest men to attempt medical 
practice after a few months' training— a very old story ; 
nor is there anything new to be learned from the creation 
of a new field for quacks. The potentialities for harm in 
these two classes are so great and so well known that it 
is really a waste of time to refer to them. Public safety 
demands that men permitted to treat any diseases must 
be learned men, at least learned in the parts they need 
— anatomy and all the other basic branches. Nor is 
there anything to be learned from the fact that this new 
fad offers a field for the use of suggestion in neurotic 
complaints — every bold assurance of cure does that. A 
learned London physician has even shown that there are 
great therapeutic benefits in prayer in calming hypersensi- 
tive nerves and diminishing mental irritability. It is 
the reason why certain ^motional religions, as distin- 
guished from the cold reasoning ones, are so much more 
popular and beneficial to the nervous and emotional parts 
of the community. The real lesson from osteopathy, 
which the medical profession must learn, is the fact that 
massage and passive movements have a much wider 
field of usefulness than is generally supposed. It is a 
therapeutic measure often sadly neglected by the intel- 
lectual doctor who will prescribe a drug, but is not a 
mechanic in any sense of the word. Such manual labor 
should not be impractical, though it apparently is. The 
average patient cannot afford a masseur and doctor, too, 
when he needs both. If the osteopath will confine his 
mechanical labors to the direction dictated by a learned 
physician, he might be of benefit indeed, but if he is to 
assure the public that 95^ of all diseases are thus cured, 
he is a menace to public safety. There c&n be no com- 



promise on that point, but it can never be an excuse for 
persecution of men, many of whom are honest, though 
fanatically deluded. Making martyrs of them will only 
perpetuate an illogic fad, which is sure to die of inani- 
tion in time. 

A problem in practical ethics is before the local 
profession probably of every city in the United States, 
and in the larger cities it is multiplied a number of 
times. Let us take one definite example as a type : 
Before his sins — at least before his fellow practitioners 
have " found him out " a man gets into the local medical 
societies and establishes a fair reputation and practice. 
Soon are told stories, both by patients and by physicians, 
and dark hints, or sorry evidences of trickery appear 
about the man. It is found that he is playing all sorts 
of fraudulent games with his patients to make money ; 
he demands visits not medically required so long as the 
patience of the patient, and his pocket-book will endure 
it. He smuggles in an unnecessary operation or two. 
If the bill is not paid there is a legal suit or a threat 
of it, until the poor dupe settles as best he or she may, 
usually paying in full to avoid trouble and to be done 
with the sharper. Expensive medicines of a peculiar 
character, or even instruments have perhaps also been 
ordered. There has been little or no cure of the disease, 
and when possible, there has been only an imagined, or 
encouraged, sometimes even a diabolically created dis- 
ease present. The scamp intimidates his patients, gets 
new ones, heaven knows how, and while growing from 
bad to worse, covers up his deviltries so dextrously that 
legal proof of unprofessionalism cannot be got. His 
ways become known to censors and colleagues ; each 
shrinks from the danger and the odium of exposing 
him, and so the infamy goes on. The local and the 
general professional reputation suffers, and the good 
name of medicine is degraded, while disgusted patients 
go over to quackery, saying, "These doctors must be 
much alike, or they'd run such fellows out of their 
medical societies, or ' show them up ' in some way." 
We invite our subscribers to say what they would advise 
in such cases. 

Gumption is so rare that any book on the subject 
should be rare reading, and so it is. Would we had 
more of it and of them. It makes the mare go even 
more than money, for gumption brings the money, and 
that makes her go anyway. It is merely common sense, 
of course, but that is uncommon sense after all. So it is 
good to read of men with gumption, and Mr. Nathaniel 
C. Fowler has described quite a few of them in his de- 
lightful novel,' telling of quite a few gumps beside. 

> Gamption : Small, Manard &, Co., Boston. 



Januaky 20, 1906T 
Vol-. XI, No. 3 J 



EDITORIAL COMMENT 



tA.MBRICAN MBDICIKE 83 



^As a bait, he starts out with a character sketch of the old 
style country doctor so chockful of gumption that it just 
simply oozes out at every pore. "Day by day he pil- 
grimaged to the outlying towns, curing as he went" — and 
did it all with castor-oil. Babies didn't cry for castoria 
in those days — and don't yet. After being hooked good 
and fast by the first chapter a physician is compelled to 
swallow the whole book, he can't get away from it. The 
young physician just starting out ought to know a little 
more than he learns in his lectures ; if he has gumption 
he will learn it anyhow, but the chances are he hasn't 
got it and should read " Gumption " to learn that in 
dealing with sick men the personal equation of the in- 
valid is the thing to study. It is really as important to 
know '* what kind of man the disease has got as to know 
what kind of disease the man has got," so that what 
seems to be trickery is merely winning confidence, upon 
which many an invalid starts to recover at once. It's 
the kiss on the baby's bruise — satisfying and curative. 
After all, most of us only want a little sympathy when 
we are sick, and, like big babies, we pine if we don't get 
it. Patients pay well for it, and the successful doctor 
dispenses it with his drugs, while the learned fool, who 
hasn't any sympathy to spare, is a flat failure, though 
his treatment in other ways may be therapeutic perfec- 
tion. 

City parks are the subject of an extensive report of 
the Philadelphia Allied Organizations, in which are 
described and mapped the existing and proposed parks 
and driveways in numerous American cities. There is 
probably no modern movement more conducive to 
public health than the widespread desire of city people 
for more breathing room. Man is not a city animal at 
all ; he was evolved in the country with unlimited fresh 
air and pure water. The city environment is so un- 
natural and so destructive of vitality that few families 
survive it many generations. The adults are not harmed 
80 much as the children, so that it is quite common to 
see a country bred man live to old age in the city and 
witness the death of most of his children, and if they 
do survive, their children are apt to be still more frail. 
London thus receives and has always received a stream 
of country immigrants who melt away. Anthropol- 
ogists assert, therefore, that cities are consumers of 
population. Until the present century there were only 
two or three big cities in the world, but with the 
wonderful development of manufactures following the 
I)erfection of the st«am engine, the people were com- 
pelled to leave the little villages where each house was 
a little factory and bunch together in factory towns. 
New methods of preserving and transporting foods also 
made this possible. Hence we saw the wonderful town 



growth of the last 70 years, European cities outstrip- 
ping us in spite of our boasts. The process was so rapid 
that houses were crowded together and an environment 
created in which no family can long survive. 

Modern rapid transit dissolved the greater part of 
the evil like magic. Men, who a quarter century ago 
could not leave the city, can now live in the country 
and come in every day. Children are being raised 
under ideal conditions, and the city man is nearly as 
well off as his grandfather was in the country village. 
Yet there are millions left behind in the cities and 
among them the deterioration continues. The present 
tendency all over the world seems to be in the direction 
of tearing down a block of houses here and there and 
creating local parks and playgrounds to get the children 
outdoors, where they belong and yet not in the streets, 
breathing germ-laden dust. By all means let this move- 
ment continue until all cities are so spread out as to 
resemble our ancient green villages, with plenty of 
breathing room and no dust. The majority of Amer- 
icans must live in cities, and it is high time they make 
conditions so natural that we will no longer confess that 
cities are consumers of population. Even the business 
portion of our cities can be improved. In summer they 
are now like huge cauldrons boiling the bodies of the 
poor victims of the rush for gold. In the residence por- 
tions the matter is positively vital — lawns, shade trees, 
dustless streets, no glare in summer, pure air and plenty 
of it, and the babies out rolling in the grass. 



Doping the Immigrant. — Immigration officers 
state that there is an extensive business in doctoring 
immigrants so that, while really unfit, they can pass the 
physical examination at Ellis Island, says the Philadel- 
phia Press. When past the barrier, they are at liberty 
to relapse, and do so promptly. In many foreign cities 
there are hospitals for the treatment of people anxious 
to enter the United States. Especial attention is given 
to trachoma, an eye disease much dreaded here. One 
conscienceless Frenchman has made a fortune by this, 
largely through treating for the malady people who 
never had a touch of it. As these pass the examination, 
as a matter of course, they constitute a fine advertise- 
ment for the charlatan. Those really aflfected get tem- 
porary relief, the telltale symptoms abating long enough 
to serve the purpose. The idea is new only in this par- 
ticular application. Horse traders resort to similar 
methods. Some of them can so doctor a decrepit animal 
that for the nonce he is spirited, his coat .shines, and he 
has a pleasing plumpness. Soon after a sale he collapses 
like a balloon. Horses are doped just before a race, and 
run with an artificial speed and strength, but the method 
fails to win approval. The immigrant that cannot pass 
muster until he has been doped should not be admitted. 
The possibility of his attempting it demonstrates the 
necessity for more rigid inspection. He makes essential 
a longer period of detention, and it may become impera- 
tive to analyze him for traces of adrenalin. The im- 
portation of healthy immigrants is desired, but infec- 
tious maladies must be kept under the ban, even to the 
discomfiture of the doped alien. 



84 Amkbican MedicinbI 



REVIEWS 



EJakcaky 20, 1906 
Vol. XI, No. 3 



BOOK REVIEWS 



Kraukheiten and Ehe. — Darstellung der Beziehungen 
zwischen Gesundheits-Storungen und Ehegeinein- 
schaft, II und III, Teile. Herausgegeben von 
Prof. Dr. H. Senator und Dr. med. S. Kamixek. 
Rebman Company, New York. 

This work, of which the first part has previously 
appeared in German, and which will soon be published 
in the form of an authorized English translation, is made 
up of a number of subsections, each of which deals with 
the diseases of a special organ and their relation to mar- 
riage. Each section is written by the most eminent 
German authority on the subject of which it treats. The 
writer takes up every disease separately and discusses its 
relation to the sexual life of both man and woman, also 
the influence of marriage on the course of the disease, 
the advisability of contracting marriage, the effect on 
possible offspring, and other questions of a highly im- 
portant nature. Senator himself contributes the first 
section of Part II, a section devoted to constitutional 
diseases — diabetes, gout, obesity, etc. H. Rosin dis- 
cusses diseases of the blood, paying special attention to 
the hereditary aspect of hemophilia. On account of the 
weUknown peculiarities in the transmission of this con- 
dition, he denies the privilege of marriage to all female 
members of hemophiliac families, but allows the males 
to marry, whether or not they themselves are bleeders. 
E. von Leyden and W. Wolff write on the diseases of 
the circulatory apparatus and point out the dangers of 
pregnancy to a woman suffering from heart disease. The 
next section, on respiratory diseases, is taken up largely 
with the tuberculosis question, which is ably discussed 
by S. Kaminer. So far as the influence of marriage on 
the course of the disease is concerned, the regular habits 
of wedded life are apt to have a favorable effect in the 
case of the man, but pregnancy is always a source of 
great danger in the tuberculous woman. The questions 
of contagion and heredity in relation to tuberculosis are 
thoroughly discussed. The author recommends a proba- 
tion period of at least three years after apparent cure 
before marriage should be allowed in a tuberculous sub- 
ject. The chapters on diseases of the digestive tract by 
C. A. Ewald, and on the kidneys by P. F. Richter are 
concerned chiefly with a consideration of the effects of 
pregnancy on these organs, both in a normal and in dis- 
eased conditions, in the section on diseases of the 
skeletal system, A. Hoffa pays special attention to the 
relation of pelvic and spinal deformities to pregnancy 
and labor. R. Ledermann contributes the chapter on 
syphilis, and advises marriage only after the lapse of at 
least five years from the time of infection, provided no 
symptoms have appeared for two years, and a thorough 
mercurial cure has been undergone. To the discoverer 
of the gonococcus naturally falls that most important 
chapter on the relation of gonorrhea to marriage. In 
cases of chronic urethral discharge, where the presence 
or absence of the specific organism is in doubt, Neisser 
recommends that an acute inflammation be induced by 
mechanical and chemic irritation. By the method 
which he describes, not only are latent gonococci brought 
to light, but a favorable influence is also exerted on the 
chronic inflammatory process. It is only by most care- 
ful examinations and thorough treatment in every case 
of gonorrhea that disastrous marital consequences can be 
avoided. The sections on the male genitourinary tract 
and the female organs are placed in the competent 
hands of C. Posner and L. Blumreich, respectively. A. 
Eulenburg has written a most interesting, entertaining, 
and instructive chapter on the relation of nervous dis- 
eases to marriage. Sexual perversion is discussed by A. 
Moll, who cautions against advising marriage as a cure 
in such cases. A. and F. Lefi"mann contribute the chap- 
ters on alcoholism, morphinism, and occupational dis- 
eases in their relation to marriage. They advise 



strongly against the marriage of alcoholics, and even 
believe that the State should interfere and forbid the 
banns, calling special attention to the effects of alcohol- 
ism on offspring. In a valuable section S. Placzek ad- 
vises caution in the matter of professional secrecy where 
the physician knows that a candidate is unfitted phys- 
ically for marriage. In the concluding chapter R. 
Eberstadt discusses marriage and disease from the moral, 
sociologic, and economic points of view. The demand 
for a higher moral code in women than in men is 
explained by the fact that nature has provided that a 
child shall know its own mother, but right and ethics 
must provide that it knows its own father. It is thus 
evident that the editors have collected a series of val- 
uable articles on a subject to which far too little attention 
has previously been paid. We hope that the publication 
of this work, with its translation, will lead to a broader 
dissemination of its truths among the medical profession 
and a wider application of its advice in the choice of the 
parents of our children. 

A Textbook of Practical Therapeutics. — By Hobart 
Amory Hare, M.D., B.Sc. Philadelphia: Lea 
Brothers & Co., 1905. 

This weUknown book has been revised to conform 
to the new United States Pharmacopeia and to enable 
comparison to be made with the British Pharmacopeia. 
Otherwise, it retains the features which have char- 
acterized it through every other edition. 

The Miorotomist's Vade-Mecmn. — By Arthur 
BoLi,ES I.EE. Sixth edition. Philadelphia: P. 
Blakiston's Son & Co., 1905. 

But little need be said regarding this edition of Lee's 
work except that laboratory workers are pleased to see 
the somewhat delayed revision. The book is in a class 
by itself, both as regards references to the statements of 
other writers and the personal comments of the author ; 
the latter are particularly incisive. The index contains 
300 new subjects, but the book has been kept to its orig- 
inal size by severe condensations. It will continue to be 
the last court of resort in the subjects treated. The accu- 
racy of the formulas is generally above reproach, but one 
error has been continued from the previous edition. In 
the formula for Toison's solution, page .386, the quantity 
of methj'l violet is given as 0.25 gm. instead of 0.025 gm. 
Personally, we use more than the latter amount, but the 
former is entirely too much. 

BOOKS RECEIVED. 

[Prompt acknowledgment of books received will be made in this 
column, and from time to time critical reviews will be made of those 
of interest to our readers,! 

Clinical Obstetrics.— By Robert .Iardine, M.D. (Edin., 
M.R.C.S. Eng,, P.F.P. and S. Glas., P.R.S. Edin.), Professor of 
Midwifery in St. Mungo's College, Glasgovr, etc. With 96 
illustrations and a colored plate. Second edition. Rebman 
Company, New York, 1905. Price, ?i4.75. 

liBctures on Clinical Psychiatry.— By Dr. Emil Krae- 
PEiiN, Professor of Psychiatry in the University of Munich. 
Authorized translation from the second German edition. 
Revised and edited by Thomas Johnstone, M.D., Edin., 
M.R.C.P. Lond., Member of the Medico-Psychological Associa- 
tion of Great Britain and Ireland. Second edition. William 
Wood & Co., New York, 1006. 

A Compend of Medical Chemistry. — Inorganic and 
Organic, including Urinary Analysis. — By Henry Leffmann, 
a.m., M.D., Professor of Chemistry in the Woman's Medical 
College of Pennsylvania and the Wagner Free Institute of 
Science. Fifth edition, revised. P. Blakiston's Son & Co., 
Philadelphia, 1905. 

Transactions of the Association of American Physi- 
cians.— Twentieth Session held at Washington, D. C, Majr 16 
and 17 1905. Volume xx. Printed for the Association, Phila- 
delphia, 1905. 

Gallstones and Their Sargical Treatment. — By B.G. A. 
Moynihan, M.S. (London), F.R.C.S., Senior Assistant Surgeon 
to Leeds General Infirmary, Leeds, England. Second edition, 
revised and enlarged. Octavo of 458 pages, beautifully illus- 
trated. Philadelphia and London : W. B. Saunders A Co., 1905. 
Cloth, $5.00 net; half morocco, $6.00 net. 



JANUARY 20, 1»06-| 

Vol. XI, No. 3 J 



AMEEICAN NEWS AND NOTES 



[Amekican Mbdicii^b 86 



AMERICAN NEWS AND NOTES 



GENERAIi. 

Opponents of Pure Food Bill. — J. A. Yerington, 
of Chicago, chairman of the Board of Directors of the 
National Food Manufacturers' Association, is in Wash- 
ington to appear before the committees of Congress to 
advocate the views of the association on food legislation. 
He says the association is opposed to the Hey burn bill, 
and will urge that the manufacturer be held responsible 
for the character of the goods shipped by him only while 
those goods remain in the original unbroken package in 
the form packed by him for shipment, and only while 
the article relates to interstate commerce and is subject 
to the provisions of a national law.; 

Joint Medical Board. —President has appointed a 
joint board composed of officers of the medical depart- 
ment of the Army and Navy to consider improvements 
in the matter of first-aid dressings and the advisability 
of the adoption of a uniform equipment in the medical 
department of the two principal branches of the military 
service. The members on the part of the Army are 
Colonel Valery Havard, assistant surgeon, medical ob- 
server with the Russian army, now stationed at Gov- 
ernor's Island, N. Y. ; Captain Charles Lynch, general 
staff, the medical officer with the Japanese army, now 
stationed in Washington, and Captain Carl R. Darnall, 
who is in charge of the field medical supply department 
in Washington. The representatives of the Navy on the 
board are Medical Director J. C. Wise, commanding the 
naval medical school in Washington ; Surgeon C. F. 
Stokes, professor of surgery at the naval medical school, 
and Surgeon W. C. Braisted, the naval medical observer 
with the Japanese forces. The main purpose in the 
appointment of this joint board is to take advantage of 
the observations of the United States military observers 
during the recent war between Japan and Russia, w.ith 
a view to the adoption in the United States military serv- 
ice of improved methods of using first-aid dressings in 
the cases of men wounded by either land or naval 
engagements. 

Personal. — Dr. R. Biirton-Opitz, adjunct profes- 
sor of physiology at Columbia University, who has for 
some years been the American editor of the Biochemische 
Cenfralblatf, has also become American editor of the 
Bio-physikalisohe CentralblcM and of the Hygienische 
Centralblatt. — Prof. Schweninger, famous as Bismarck's 
body physician, has resigned as head of the famous 
infirmary near Berlin, and will devote the evening of 
his life to private practice chiefly among the poor and 
destitute. — Dr. Koch has been placed at the head of an 
expedition to eastern Africa to investigate the sleeping- 
sickness, for which the German government has appro- 
priated liW.OOO.— I>r. Thomas F. Richardson, of the 
Marine-Hospital Service, has been designated by its 
chief. Dr. Wyman, to go to Honduras at a salary of 
$7,500 a year from that country, to act as its health 
officer. Dr. Richardson was chief assistant to the sur- 
geon in charge during last summer's fight against yellow 
lever at New Orleans. — The General Hospital Board of 
Virginia, composed of the directors of the different State 
hospitals for the In.sane, has appointed Dr. William P. 
Drewry superintendent of the Western State Hospital, 
at Staunton, to fill the vacancy caused by the death of 
Dr. Benjamin Blackford. — Baron K. Takaki, Surgeon- 
1 General of the Imperial Japanese Navy, has arrived on 
] the Siberia, to deliver a series of lectures on " Military 
I Sanitation" at Columbia University and at Jefferson 
! Medical College, in Philadelphia. He will meet his son 
' in Philadelphia, where the young man has been .study- 
ing finance and commerce at the University of Pennsyl- 
vania. Baron Takaki is distinguished because of his 
discovery 22 years ago of means for preventing beriberi, 



a disease previously quite common in Japan, but which 
has never since seriously affected the men in the navy. 

NEW YORK AND VICINITY. 

Dog Carried Scarlet Fever. — The young son of 
James Byrne, official sealer of weights and measures at 
Orange, N. J., died of scarlet fever contracted from play- 
ing with his dog, which had strayed into a house where 
several children were ill with the disease. 

The Cartwright Lectures of the Alumni Associa- 
tion of the College of Physicians and Surgeons of 
New York will be given on January 25, January 29, and 
February 2, by Baron Takaki, on " Military and Naval 
Sanitation ; Experiences Drawn From the Late Japan- 
Russia War." Dr. Takaki belongs to one of the Samurai 
families of the Satzuma Clan, as do his contemporaries. 
Generals Oyama, Kurobi, Nogi, and Nodzu, and Ad- 
mirals Togo and Kammura. During his youth he was 
sent by his government to study medicine in England, 
where he graduated with honor from St. Thomas' Hos- 
pital School, studied the sanitary system of the British 
Navy, and passed examinations for the degrees of F.F.C.S. 
and F.R.C.P. On his return to his native country he 
directed his chief attention to the reformation of the 
sanitary and medical systems of the newly-born navy of 
Japan. It was not only reorganization that he accom- 
plished, but the creation of an entire medical equipment 
and medical sanitary service for the Japanese Navy. He 
was rapidly promoted to the rank of Surgeon-General of 
the navy, which position he held until the time of the 
Japan-China war. As a recognition of his great services 
rendered to the Emperor and his country, he was created 
a baron after the conclusion of that war. At present he 
is in the Naval Reserve. During his active service in 
the navy Baron Takaki initiated and carried out certain 
fundamental changes in the dietary and sanitary regula- 
tion of the navy, which resulted in the almost total sup- 
pression of beriberi, which, up to that time, had seriously 
impaired the efficiency of the service, affecting annually 
almost a quarter of the navy's personnel. Baron Takaki 
has also been president of the Naval Academy of Japan, 
president of the Tokyo Charity Hospital, councillor of 
the ^\s90ciation of Sanitary Improvement of Japan, and 
has held other important positions. He has been active 
in spreading the principles of the Red Cross Society in 
Japan and it is to his efforts that the large number of 
Red Cross members in that country is chiefly due. 
Baron Takaki has received the honorary degree of Doctor 
of Medicine of the Japanese Government, a degree issued 
only by the Department of Education, and not the same 
as the degree of M.D. conferred on the graduates of the 
university. He is a member of the House of Peers of 
the Parliament of Japan, having been directly nom- 
inated by the Emperor. 

PHIIiADEIjPHIA, PENNSYLVANIA, ETC. 

Veterinarians Want State Board. — The Veteri- 
nary Medical Association of New Jersey, at its annual 
meeting, urged that a bill be framed and sent to the 
Legislature providing for the appointment of a State 
Veterinary Board of Health. It was asserted that a 
veterinarian is better qualified to decide what should be 
done with diseased animals than a medical doctor. Com- 
mittees will be appointed to consider this proposition 
further. 

Measles Increasing. — Measles has become epidemic 
in the West Philadelphia wards, and additional instruc- 
tions have been issued by the health authorities caution- 
ing parents to isolate cases of the disease. The spread 
of the disease is attributed by Dr. A. C. Abbott, chief of 
the Health Bureau, largely to the fact that parents 
neglect to summon a physician to treat their children. 
There are many cases of diphtheria in Philadelphia, 
which the authorities believe are due to the failure of 
physicians to use antitoxin. 



86 Ambbican Mbdicinkj 



FOEEIGN NEWS AND NOTES 



rjANDARY 20, 1906 

LvoL. XI, No. 3 



Typhoid Fever in Wilkinsburg, — An epidemic of 
typiioid fever prevails in tiie borougli of Willtinsburg, 
'adjacent to Pittsburg. Tiiere are now more tlian 100 
cases of the disease and a number of deaths have 
resulted. A determined effort has been made by the 
Board of Health to find the source of contagion, but the 
investigation has completely failed. Samples of water 
taken from public springs have been brought to Pitts- 
burg for analysis. 

College of Physicians, at its annual election, chose 
these ofHcers : President, Dr. Arthur V. Meigs ; vice- 
president, Dr. .James Tyson ; censors, Drs. Richard A. 
C'leemann, S. Weir Mitchell, Horace Y. Evans, and 
Louis Starr ; secretary. Dr. Thomas R Neilson ; treas- 
urer. Dr. Richard H. Harte ; honorary librarian, Dr. 
Frederick P. Henry ; councillors, Drs. J. Allison Scott 
and Francis R. Packard ; Committee of Publication, Drs. 
G. G. Davis, Thompson S. Westcott, and William Zent- 
mayer; Library Committee, Drs. George C. Harlan, F. 
X. Dercum, Charles A. Oliver, William J. Taylor, and 
S. Weir Mitchell. 

Typhoirt Fever Increasing. — Continued increase 
in the number of typhoid fever cases is attributed by the 
health authorities to the condition of the city's water 
supply and especially to the neglect of householders to 
heed the warning to boil all drinking water. There 
were 267 new cases reported last week, as compared 
with 197 the previous week, an increase of 70. Of the 
whole number of new cases, 75 occurred in live wards in 
the northeast district of the city, which are supplied 
with water from the Delaware river, and 20 cases in 
West Philadelphia, which is supplied with a mixture of 
filtered and unfiltered water. The returns of contagious 
diseases show that there were 416 cases and 40 deaths 
last week, as compared with 341 cases and 36 deaths the 
previous week. 

New Rules for Burials. — Owing to the fact that 
cemetery sites have been selected without regard to the 
geological formation, many of which are not suited for 
the purpose of properly protecting the health of the per- 
sons in their respective localities, the State Department 
of Health has decided to adopt the following rule and 
regulation: "Except by special permission from the 
Department of Health, no interment of any human 
body shall be made in any public or private burial 
ground unless the distance from the top of the box con- 
taining the coffin or casket be at least five feet from the 
natural surface of the ground, except where solid rock 
or water may be encountered. Then the distance from 
the top of the box containing the coffin or casket shall 
be not less than four feet from the natural surface of the 
ground ; and with the further exception that stillborn 
children and children less than 4 years of age, dead of 
any diseases other than anthrax, cholera, diphtheria, 
leprosy, smallpox, scarlet fever, tetanus, typhoid fever, 
typhus fever or yellow fever, shall be buried at such a 
depth that the top of the box containing the coffin or 
casket be not less than three and one-half feet from the 
natural surface of the ground." 

SOUTHERN STATES. 

Mosquito Ordinance Amendment. — Dr. Kohnke, 
the New Orleans Health Officer, will talk on the petition 
of a number of gardeners, truck farmers, and florists in 
the city, who are seeking an amendment of the mosquito 
ordinance so as to secure the omission of the word " well " 
before the petition is finally acted upon by the com- 
mittee. It has been stated that Dr. Kohnke does not 
object to the amendment being made as asked. The 
petitioners argue that open wells are breeding places for 
small fish, called minnows, who thrive on the larvas of 
mosquitos. If these wells are closed, they contend, the 
water will become stagnant and brackish and unfit for 
use. The screening of an open well, petitioners state, 



would entail a hardship by subjecting them to unneces- 
sary expense in the operation of their business. 

WESTERN STATES. 

Anticigaret Bill in Ohio.— A bill framed after the 
Indiana law to forbid the sale of cigarets will be intro- 
duced in the Ohio legislature. 

War on Tuberculosis.— Action has been taken by 
the Chicago school management committee which makes 
it possible that any child afflicted with tuberculosis can 
be taken from the schools. When a case of tuberculosis 
is suspected the principal must report it to the superin- 
tendent of schools. After the parents of the child are 
notified the pupil will be examined by medical inspec- 
tors of the child study department. The parents will be 
allowed to have their family physician present if they 
so desire. 

Chicago's Low Deathrate. — December, 1905, was 
one of the dryest months on record, according to the 
weekly bulletin of the Chicago Health Department, 
The total precipitation for that month was .68 of an 
inch, the average ot 35 years being 2.05 in. Prof. Cox's 
report to the city shows that the mean temperature was 
2.7° higher than the normal, and that only 10 previous 
Decembers had a higher mean temperature. Tliese con- 
ditions undoubtedly have had much to do with making 
the December deathrate the lowest on record. The 
opening week of the new year, although not fully main- 
taining the record of the previous month, was reported 
to be satisfactory. 



FOREIGN NEWS AND NOTES 



GENERAL. 

Prussia's Scourge. — Of the 702,147 deaths recorded 
in Prussia in 1904, 69,326 were caused by tuberculosis 
and 54,815 by pneumonia. 

" Nose-drinking," a New "Vice. — In Norway there 
is a short cut to intoxication much favored in the city 
slums. The drunkard fills the palm of his hand with 
" aquevit " (strong corn brandy) and sniffs it through his 
nose. A few applications do the work, while the same 
quantity of liquor taken into the stomach would hardly 
be felt. " Nose-drinking " has become a real vice with 
some individuals, Norwegian papers say. The effect of 
it is terrible, because the whole nervous system is para- 
lyzed in a moment, and the drunkard remains almost 
unconscious for several minutes. Afterward a sleepy 
fatigue is felt, as after smoking opium. 



OBITUARIES. 

Sclwyn A. Russell, January 11, at his home in 
Poughkeepsie, N. Y. He was graduated from Albany 
Medical College, Albany, N. Y., in 1877. Dr. Russell's 
death was caused by his trying to obtain practical knowl- 
edge by testing his theory that people eat too much ; he 
had taken no food for a week. 

Robert W. Steger, of Chicago, was found in an un- 
conscious condition, due to a dose of chloroform and 
morphin, in a hotel in New York, and died in Bellevue 
Hospital January 2. He was graduated from the Uni- 
versity of Nashville, medical department, in 1877. 

E. C. Dent, January 12, suddenly, from heart dis- 
ease, at his home in New York City. He was graduated 
from Bellevue Hospital Medical College in 1879, and for 
25 years served as superintendent of the Manhattan State 
Hospital on Ward's Island. / 

William B. Stoner, aged 60, of Sunbury, Pa., Jan- 
uary 9, at the Clifton Springs Sanatorium, N. Y. He 
was graduated from the Kentucky School of Medicine, 
Louisville, Ky., in 1892. 



JandARY 20, ]90fi"l 
Vol. XI, No. 3 J 



THE PUBLIC SERVICE 



JAmekican Mkdicinh 87 



M. E. Chartier, Januarj' 8, suddenly, in Biloxi, 
Miss. He was graduated from the University of Paris. 
His work was mostly among the poor, for which he 
made no charge. 

Alexius li. Middletou, aged 73, January 8, sud- 
denly, at his home in Piseataway District, Prince George 
County, Md. 



THE PUBLIC SERVICE 



Changres in the Medical Corps of the U. S. Army 

for the week ended January 13, 1905 : 

So much of orders of September 11, as direct First 
Lieutenant Allie W, William.s, assistant surgeon, to 
proceed to the Philippine Islands on the transport to sail 
from San Francisco, Cai., January 5, are so amended as 
to direct him to report at San Francisco for duty as sur- 
geon of the transport Meade during the next voyage of 
that transport to Manila, P. I. — Edward Oole, ser- 
geant first class, now at Cleveland, O., is relieved from 
further duty in the Philippines Division, and on or 
before expiration of furlough will report at Fort Ethan 
Allen for duty.— George Reynold.s, sergeant first 
class, Vancouver Barracks, will be sent to San Francisco, 
Cal., reporting to the medical superintendent, army 
transport service, for duty aboard the transport Meade. 
—William D. Evax.s, sergeant first class, Key West 
Barracks, will be sent to Fort McPherson for duty. — 
Rush Camebox, sergeant first class. Fort Adams, will 
be sent to New York city, reporting to the medical 
superintendent, army transport service. Army build- 
ing, for duty aboard the transport McClellan. — First Lieu- 
tenant Philip W. Huxtixgtox, assistant surgeon, will 
upon his arrival at San Francisco, Cal., proceed to Fort 
Rosecrans for duty.— Geokoje Newlove, contract sur- 
geon, extension of leave granted October 21 is further 
extended 15 days. Upon the expiration of his present 
leave will proceed to New York city for duty as surgeon 
of the transport McClellan during the next voyage of 
that vessel to Manila, P. I. — The following-named 
officers are assigned to stations as follows, for duty : 
Captain Joseph H. Ford, assistant surgeon, to Mala- 
bang ; First Lieutenant Clarence L. Cole, assistant sur- 
geon, to Cotabato; Captain George P. Peed, assistant 
surgeon, to Camp Overton ; First Lieutenant James W. 
Van Dusen, assistant surgeon, to Camp Keithley ; First 
Lieutenant George W. Jean, assistant surgeon, to Jolo, 
Jolo. First Lieutenant William P. Banta, assistant 
surgeon, will proceed to Camp Stotsenburg, Pampanga, 
for duty. — First Lieutenant E. D. Kilik)UBXE, a.ssistant 
surgeon, is granted leave for one month.— First Lieu- 
tenant Joiix H. Allex, assistant surgeon, is granted 
leave for 20 days, to take effect upon return of Contract 
Surgeon Harry H. Van Kirk to duty at Fort Sill.— 
Clakexce F. Diokexson, contract surgeon, is relieved 
from duty at Fort Logan and will report to the com- 
manding officer. Second Infantry, for duty to accompany 
that regiment to the Philippine Islands. Upon arrival 
at Manila he will report to the commanding general, 
Philippines Division, for a.ssignment to duty. — Wal- 
lace E. Pakkmax, contract surgeon, leave granted 
October 18 is extended one month.— Samuel A. Weik, 
sergeant first class, Plattsburg Barracks, will be sent not 
later than January 25 to New York city, reporting to 
the commanding officer, transport McClellan, for trans- 
portation to Manila, P. I. — Frederick S. Macv, con- 
tract surgeon, upon the abandonment of Allegheny 
Arsenal, Pa., and the completion of the duties to which 
he has been assigned by the commanding general, 
department of the East, will proceed to Fort Adams for 
duty.— So much of orders, October 4, as direct that 
Sergeant First Class Paul Comptox will be sent to the 
depot of recruits and casuals. Fort McDowell, are 



revoked.— Paul Comptox, sergeant first class, now at 
Morrow, O., having relinquished the unexpired portion 
of his furlough, will report at Fort Wayne not later than 
January 18 to accompany the First Infantry to Manila, 
P. I. — J. Samuel White, contract surgeon, is relieved 
from further duty at Fort Snelling, and at the expiration 
of his present leave will proceed to Governor's Island, 
N. Y., and report for assignment to duty to accompany 
the First Infantry to the Philippine Islands. Upon 
arrival at Manila he will report to the commanding 
general, Philippines Division, for assignment to duty. 

Changes in the Medical Corps of the U. S. Navy 

for the week ended January 13, 1906 : 

P. Leach, surgeon, detached from the Massachusetts, 
when placed out of commission, and ordered to the 
Indiana.— W. A. Angwix, assistant surgeon, detached 
from the Massachusetts, when placed out of commission, 
and ordered to the Indiana. — L. O. Schetky, pharma- 
cist, ordered to the Naval Hospital, Norfolk, Va. — T. C. 
Blackbukx, acting assistant surgeon, detached from 
the Franklin, ordered home, and granted leave until 
expiration of appointment as acting assistant surgeon, 
January 23.— E. E. Curtis, acting assistant surgeon, 
ordered to the Franklin.— P. F. McMuhdo, acting assist- 
ant surgeon, detached from the Franklin, ordered home, 
and granted leave until expiration of appointment as 
acting assistant surgeon, January 23.— J. T. Miller, 
acting assistant surgeon, ordered to the Franklin, Janu- 
ary 15. 

Changres in the Puhlic Health and Marine-Hos- 
pital Service for the week ended January 10, 1906 : 

EuciENE Wasdix, surgeon. Leave of absence 
granted Surgeon Wasdin for one month from December 
15, 1905, amended so as to be effective from December 
17, 1905.— P. M. Carbingtox, surgeon, directed to pro- 
ceed to El Paso, Texas, for special temporary duty. — J. 
A. Nydegger, passed assistant surgeon, granted leave 
of absence for one day, January 2, 1906. — E. K. 
Sprague, passed assistant surgeon, relieved from duty 
at Ellis Island, N. Y., and directed to proceed to Cape 
Fear Quarantine Station and assume command of the 
Service. — Jos. Goldbergeb, passed assistant surgeon, 
relieved from special temporary duty at New Orleans, 
and directed to rejoin his station In Washington. — B. H. 
Earle, passed assistant surgeon, granted leave of ab- 
sence for four months from February 4, 1906.— R. E. 
Ebersole, assistant surgeon, relieved from duty at 
Tampa Bay Quarantine, and directed to proceed to San 
Francisco, Cal., and report to the medical officer in com- 
mand for duty and a-sslgnment to quarters. — F. H. Mc- 
Keon, assistant surgeon, relieved from duty at New 
Orleans, La., and directed to proceed to San Francisco 
Quarantine Station, reporting to the medical officer in 
command for duty and assignment to quarters. — R. D. 
Spratt, assistant surgeon, relieved from duty at Louis- 
ville, Ky.,and from temporary duty at Gulf Quarantine 
Station, Miss., and directed to proceed to Mobile, Ala., 
assuming temporary charge of the service at that port. — 
M. C. Guthrie, assistant surgeon, relieved from duty at 
Cape Fear Quarantine Station, and directed to proceed 
to New York and report to Surgeon Stoner, Ellis Island, 
N. Y., for duty. — L. C. Beax, acting assistant surgeon, 
granted leave of ai)sence for two days from January 8, 
1906. . 

Boards Convened. — Board convened to meet at Boston, 
Mass., for the physical examination of an inspector in 
the Immigration Service. Detail for the board : Surgeon 
R. M. Woodward, chairman ; Acting Assistant Surgeon 
F. H. Cleaves, recorder. Board convened to meet at 
Philadelphia, Pa., .January 9, 1906, for the physical' 
examination of an officer of the Revenue Cutter Service. 
Detail for the board : Surgeon F. Irwin, chairman ; 
Assistant Surgeon H. McG. Robertson, recorder. 



88 [American Medicine 



SOCIETY EEP0RT8 



rJANUARY 20, 1906 

LVoL. XI, No. 8 



SOCIETY REPORTS 



THE SOUTHERN SURGICAL AND GYNECOLOGICAL 

ASSOCIATION. 

Eighteenth Annual Meeting, Held in Louisville, Ky., 

December 12, 13, and 14, 1905. 

[Specially reported for American itedicine.'i 

Surgical Repair «f Injurert Nerves. — J. Siiei^ton 
HoRSi>KY (Richmond, Va.) reviewed the work of recent 
investigators on the histologic regeneration of nerves. 
He alluded to the views of Bethe and others, who claim 
that regeneration of a peripheral nerve can take place 
without central connection. He classified the surgical 
methods of repair as follows : 1. Simple nerve suture, 
including all cases where the ends of the nerve are 
brought into direct contact and sutured, even when 
nerve stretching or resection of the long bone may be 
necessary. 2. Flap operations, which were usually un- 
satisfactory. 3. Nerve bridging. By this term was 
meant those cases in which a foreign substance was used 
to bridge over the defect between the ends of a divided 
nerve. This included not only transplantation of nerve 
tissue from lower animals, but also suture a distance. 4. 
Nerve implantation or anastomosis. Under this head 
were included those cases in which the ends of an injured 
nerve were implanted into a healthy nerve. He reported 
a case falling under the last classification. The patient 
had sufftered an injury, as a result of which the upper 
part of the median nerve had been destroyed for two 
and a half inches and the musculospiral injured in the 
lower part of the arm with paralysis of all muscles in 
the hand and forearm, except those supplied by the 
ulnar. Three months after this the median was im- 
planted laterally into the ulnar. Fourteen months later 
both flexion and distention had returned to a marked 
degree. At that time the musculospiral was cut across 
and implanted laterally into the median. Ten months 
after the second operation, sensation and motion of the 
hand and forearm had almost completely returned. In 
discussing several points connected with the case, Hors- 
ley concluded that the extensors must have been supplied 
through the anterior interosseous of the median, because 
flexion and extension improved simultaneously, and be- 
cause extension was not interfered with at the second oper- 
ation, when the musculospiral was completely divided. 

Discussion. — Charles H. Mayo (Rochester, Minn.) 
said one question that interested him more especially 
was the difference in the ability of repair of a sensory 
nerve and a motor nerve, also combined sensory and 
motor nerves. For instance, about the head, where we 
had the purely motor and sensory nerves it was almost 
impossible to keep a sensory nerve from uniting itself. 
It would get out and grow for inches and repair itself ; 
but a sensory nerve having peripheral impulses toward 
the center seemed to lack regeneration like a motor 
nerve in which the impulse came from the center out. 
He had taken out the infraorbital, plugged the opening 
with silver, and had a case as many as seven years with- 
out return of sensation in that area, yet within a few 
months, after operating again and removing the silver 
plug, the sensory nerve, which had been lying dormant 
for this length of time, would get out, hunt up a partner, 
so to speak, and go to work. Take the motor nerve of 
the arm, where there were acute sensory and motor 
nerves, we would get more rapid regeneration because of 
the peripheral impulses, and as the sensory nerve of the 
arm was so much in excess over that of the leg, we 
would get earlier repair in the surgery of nerves of the 
arm than we would in the leg. HorsIjEY, in closing 
the discussion, called attention to the point that his 
patient was of a low grade of intelligence, whose nervous 
system was not well developed, and the same law applied 
here as would apply to other similar cases, namely, the 
lower the type of organism, the more rapid and more 
active the repair. 



GaUstoncs in the Cystic Duct. — L. H. Dunxixg 
(Indianapolis, Ind.) presented a method which he had 
employed in a case which greatly facilitated the pressing 
backward into the gallbladder of a stone impacted in 
the cystic duct. In this case the gallstone was lodged in 
the cystic duct in front of a small stricture. After 
making all the eff'orts he deemed prudent to press the 
stone backward into the gallbladder, without success, he 
then unsuccessfully attempted to dilate the stricture with 
the finger tips and later with forceps. One of his assist- 
ants suggested that he thought they could better dilate 
with the forceps if they could see the stricture. The 
walls of the gallbladder were elastic. The liver had 
been turned upward, so that the gallbladder was near 
the surface. The opening in the gallbladder through 
which he had been working was enlarged a little, and 
then the stone was steadied and held against the stric- 
ture by an assistant. The fundus of the gallbladder 
was pushed forward toward the strictured entrance into 
the cystic duct. They so far succeeded as to bring the 
opening in the wall of the gallbladder directly opposite 
to the strictured opening. They then tried to introduce 
the forceps tips, but failed. Picking up a pair of probe- 
pointed scissors curved on the flat, the point was gently 
worked through the fistula and the scissors opened ; this 
did not dilate the opening sufficiently, so the edge of the 
fistulous ring was snipped slightly in two or three places, 
when they were able to dilate the fistula so as to permit 
the easy exit of the stone. The operation was completed 
in the usual way. A rubber tube was fastened in the 
gallbladder and that viscus anchored to the fascia. Be- 
fore they had finished the operation a little bile had 
flowed into the gallbladder. Two or three ounces of 
bile were discharged from the tube daily ; at first it was 
dark and thick, but gradually approached the normal 
color and consistency. The patient made an uneventful 
recovery and had but little further pain or soreness in 
the gallbladder region. He thought the procedure 
adopted in this case might be found of service in others. 
It was not applicable to cases in which the gallbladder 
could not be brought near the surface, or where the gall- 
bladder was thickened by inflammatory deposits. In 
the author's experience in operating upon 93 eases of 
gallstones, there were 10 cases of stone in the cystic duct 
requiring considerable effbrt to dislodge them. In two 
of the cases early in his experience, the stones were 
crushed and portions left behind, subsequently giving so 
much trouble that cholecystectomy was finally performed. 

Common Duct Obstruction. — .1. Wesley Long 
(Greensboro, N. C.) stated that, as compared with gall- 
stones in the gallbladder, the condition was many times 
more serious. He quoted the as yet unpublished statis- 
tics of the Mayo clinic, where there had been more gall- 
stone operations done than in any other clinic in the 
world, showing that in simple gallstones in the gall- 
bladder the mortality of operation was less than one-half 
of 1 ^ , while the mortality in operations for common 
duct obstruction ranged from 11.9^ in benign cases to 
40 fc in malignant cases. These facts were brought out 
to emphasize the prophylactic value of operating while 
the stones were yet in the gallbladder. Touching the 
etiology of common duct obstruction, he took the posi- 
tion that practically all cases were due either to stones 
or to malignant growths, which, themselves, were caused 
by the irritating presence of stones. Gallstones might 
exist in the gallbladder for along while without produc- 
ing symptoms, but once in the common duct, not only 
pronounced symptoms, but many serious complications 
arose. The mortality in these cases was due to the com- 
plications, the cholemia, infection, inflammation, and 
exhaustion, due to hemorrhage at the operation. He 
emphasized the fact that common duct obstruction could 
be treated only by surgical methods. After removal of 
the obstruction, the first consideration was drainage, 
since it was imperative to overcome the infection ; and, 
second, that no operation must be deemed finished until 



January W, 1906"I 
Vol. XI, No. 3 J 



SOCIETY REPORTS 



fAMKBICAN MEDICIKS 89 



the patency of the opening into the duodenum was 
assured. Attention was called to the importance of not 
removing the gallbladder in the operation of choledo- 
chotomy, since stones occasionally reformed in the com- 
mon duct, and in these cases the gallbladder served for 
drainage. A number of cases of operation for common 
duct obstruction occurring in the hands of Long were 
reported, showing the profound disturbance caused by 
the stones and the great relief afforded by their removal. 
In one case it was noted that the stones had ulcerated 
through the side of the gallbladder and into the common 
duct, an exceedingly rare occurrence. 

Gangrene of the Gallbladder ; Rupture of the 
Common Duct; a New Sign. — Joseph Ransohoff 
(Cincinnati, O.) reported a case of gangrene of the gall- 
bladder in a male patient, aged 21, with recovery fol- 
lowing operation. The second case was one of rupture of 
the common duct with an unusual sign. Operation was 
done, followed by recovery of the patient. Although 
the cases differed in many important points, they had 
enough factors in common to warrant their consideration 
together. In each of them a rapidly developing per- 
itonitis made an operation imperative as a vital indica- 
tion. In each the operation revealed a condition which to 
the naked eye at least had all the earmarks of a peritonitis, 
which might speedily cause death. In one there was an 
unruptured but gangrenous gallbladder, the contents of 
which were proved to be sterile ; in the other, there 
were large quantities of free bile in the peritoneum. He 
called attention to a sign which was noticed in the case 
of ruptured duct before the incision was made, and one 
to which he believed attention had not been directed. It 
was a localized jaundice of the umbilicus. Although a 
single case was not usually sufficient to warrant the 
assumption that something new had been observed, 
this feature was so marked that he could not refrain 
from believing that further observation would give to 
this localized jaundice some value as a sign of free bile 
in the peritoneal cavity. In the case presented this 
feature gained in interest, as the staining of the sub- 
peritoneal fat with bile was observed in the incision 
through the abdominal wall. The jaundice was doubt- 
less purely the result of imbibition. It made itself mani- 
fest first in the integument of the navel, because this 
part was thinner than the rest of the abdominal wall. 
Total gangrene of the gallbladder had to his knowledge 
not been observed except in the case presented as an 
affection independent of gallstones. Total gangrene of 
the gallbladder is rare. In the case reported a most 
careful search failed to reveal the presence of a stone. 

[To be continued. \ 



WESTERN SURGICAL AND GYNECOLOGICAL ASSO- 
CIATION. 

Fifteenth Annual Meeting, Held in Kansas City, Mo., 
December 28 and 29, 1905. 

[Specially reported for American Medicine.] 

The Transvesical Operation for the Relief of 
Prostatism in Aged Males. — Ciiarlks E. Boweks 
(Wichita, Kans.) readapaperon this subject. He stated 
that more conservative and rational operations would 
yield better results and lower the mortality percent. An 
exact diagnosis in many cases could only be made upon 
suprapubic exposure of the vesical outlet. The supra- 
pubic operation could be done with greater exactness and 
would yield better results than the infrapubic in morbid 
conditions in the male, as had been the case in the female 
pelvis. The suprapubic route was as rationally indicated 
for the relief of the above-named obstructive conditions at 
the urinary outlet as it was in vesical calculus. The 
perineal operation offered only 30% of cures, with a mor- 
tality of 7 % , and a 60 fc chance of having exchanged one 
urinary difficulty for another and not infrequently a 
lesser for a greater one ; while the transvesical operation 



entirely relieved all who survived it of their urinary 
trouble, if it was due to obstruction in and about the 
vesical outlet, except when they were carcinomatous in 
character, without sequels and with the improved oper- 
ative technic of today no greater mortality. The contro- 
versy that was now going on relative to perineal and 
suprapubic prostatectomy was only a repetition of the 
one waged when lithotomy was undergoing its evolu- 
tion. Who today cuts for stone in the male bladder via 
the perineum ? The most essential thing today was to 
bring home the facts to the profession in general : 1 . 
That protatism was due to other causes than hypertrophy 
of the prostate gland. 2. That the transvesical operation 
for prostatism had attained a sufficient degree of perfec- 
tion to be recommended to this class of pitiable sufferers, 
with the assurance of a cure if undertaken before the 
inflammatory process had reached the kidney and 
arrested its functional activity. 3. Patients should not 
be submitted to catheterism in the future as they had been 
in the past until it was hopeless to interfere surgically. 

Discussion. — Henry T. Byfokd (Chicago) in speak- 
ing of the etiology of enlarged prostate, thought the 
condition was due to some irritation ; that the condition 
could not come entirely from age alone or from the 
sclerotic changes which occurred with age. In some 
cases of enlarged prostate there was doubtless a gouty 
diathesis, and that perhaps the treatment recommended 
by Fletcher in his book, of reducing the calories from 
3,000 to 1,500, and perhaps dieting a little, would obviate 
the necessity of suprapubic prostatectomy in some cases. 
James E. Mooke (Minneapolis, Minn.) stated that 20 
years ago or more he did his first prostatectomy supra- 
pubically, and as it was done at that time it was a blind, 
bloody, and unsatisfactory operation. A few years ago, 
when perineal prostatectomy was suggested and prac- 
ticed so successfully, he took it up and had been advo- 
cating it ever since, always maintaining that there were 
certain cases that could be operated better by the supra- 
pubic route as it was done at the present time. How- 
ever, in his judgment if a man was not broadgauged, he 
did not do the best work he could do until he performed 
both operations. He believed the perineal route was 
the choice in the vast majority of cases and by the vast 
majority of surgeons. W. W. Grant (Denver Colo.) 
said he had maintained for years that in the average 
case the perineal operation was the more desirable one. 
In cases in which there were pus, hyaline and granular 
casts, the perineal route was indicated. The dirty 
cases could be better and more safely operated 
through the perineum ; the clean cases by supra- 
pubic cystotomy by the wellknown modern methods. 
J. W. Andrews (Mankato, Minn.) believed that there 
were selected cases which should be operated by the 
transvesical route, but in the majority of instances the 
perineal route was the better. He had operated 11 times, 
with one death. One of the operations was suprapubic. 
He found it difficult, unclean, and was unable to get 
good drainage. Lack of drainage was one objection to 
the suprapubic route. The drainage was not and could 
not be as good as it was through the perineum. M. L. 
Harris (Chicago) said that when one attempted to 
generalize from a few cases in surgery, these generaliza- 
tions were always wrong. The essayist had generalized 
from 12 cases that the suprapubic route was the only one 
to be done, consequently he thought he was wrong. 
There were many cases in which a good and thorough 
operation could not be done suprapubically. There were 
also many cases in which the best operation could only 
be done suprapubically ; consequently the surgeon must 
select the best operation for the particular case, lilvery 
case of prostatism should be accurately diagnosed before 
an attempt was made to select the method of operation, 
and the surgeon could only make such a diagnosis when 
he employed all the means at his command, and one of 
these was a thorough cystoscopic examination. 

[To be continued.] 



90 



American Medicini) 



COREESPONDENCE 



rjANDARY 20, 190«> 

LVOL. XI, No. 3 



CLINICAL NOTES AND CORRESPONDENCE 

[Communications are Invited for this Department. The Editor Is 
not responsible for the views advanced by any contributor.) 



LOCOMOTOR ATAXIA. 



P. M. WISE, M.D., 

of New York. 

« 

To the Editor of American. Medicine: — Locomotor 
ataxia as a disease is notorious as a resource of quackery. 
From my point of view this is largely due to profes- 
sional pessimism. If physicians would not practise 
such bald frankness with patients and assure them that 
beyond peradventure they were doomed to progressive 
and horrible disability until relieved by extinction, they 
would enhance their prerogative and be saved from voic- 
ing a material, although universal error, for tabes is 
not inevitably progressive or incapable of arrest, or even 
cure. It is not resistant to treatment. The orthodox 
treatment may be so considered, perhaps, for it consists 
largely of a mixed treatment or socalled nerve tonics, 
but symptomatic treatment and effort to relieve com- 
plications, especially disorders of nutrition, is rare indeed 
with the profession at large. 

The ataxic subject, like the tuberculous, especially in 
the earlier stages, is peculiarly hopeful. He is not in 
sympathy with his sceptical doctor, and does not believe 
he is beyond cure. Therefore when he meets a promise 
of cure, which he inevitably does, for the promise seeks 
him out as a matter of trade, he falls into the trap and 
stays as long as his money lasts. Of the wage earners 
who have come under my observation, in whom the 
duration of the disease was three or more years, penury 
has been the rule ; and it is not rare that fortunes have 
been squandered in vain attempts to regain health by 
following false promises ; for these conscienceless fakirs 
are good business men and base their demands largely 
upon the capacity of their victims to pay. In one case 
which was told to me by an observer, the patient was 
worked up to such a pitch of fear and excitement that 
he was forced to sign a check for $.5,000 before he left 
the room, or he would not be treated by what he was 
made to believe was the only way to save his life. This 
seems incredible, but the devices of these impostors are 
ingenious, and their false clinical presentments bear 
nothing of truth. His subsequent death was doubtless 
the result pf the theatric abuse of therapy he received 
for his money. Cases of this kind are not rare. Ataxic 
subjects of means are exceptional who cannot relate an 
experience of this nature, although few are as radical. 

I fancy that in large measure the bigoted intolerance 
of most physicians against anything therapeutic for 
tabes is to blame for much of the foregoing conditions. 
In the first instance the tabetic quite invariably consults 
his home doctor, who, as a rule, establishes the diag- 
nosis. This is the starting-point for "no hope who 
enters here," and the forlorn patient is turned adrift, to 
seek help elsewhere or not, as he pleases. Naturally, an 
unqualified prognosis excludes any further approach of 
the "fatalist" to confer relative to other "treatments," 
whereas the physician '(the home doctor) should always 
remain the counselor and friend, if not the medical 
attendant. A patient came to me, less than five years 
since, from a " prominent physician in America," with 
the parting advice to eat, drink, and make merry, for 
he would soon die in any event. Within a year this 
man resumed his former vocation, and is today quite 
well and happy, although in a measure disabled. With 
a discouraging uniformity, the several hundred I have 
observed since then tell much the same tale ; especially 
discouraging because it comes from the source for which 
they naturally have the greatest respe<!t. These doctors 
are often right, it is true, but this is no excuse for an 
attitude which is hurtful to both them and their patient. 



In a few instances in which I have tried to follow my 
rule of cooperating with the local doctor, I have been 
roundly denounced by him as a fraud for attempting to 
treat a patient whom he had declared incurable. In not 
a few instances the later development of these cases has 
been an exhibition of " eating crow." 

I would appeal to practitioners, who have the first 
opportunity to treat patients with locomotor ataxia, to 
assume more optimism, or at least lees prohibition of 
possibilities. At any rate keep the position of coun- 
selor and invite the patient's confidence, and you may 
save him from disaster. Do not condemn what you do 
not know or have not tried. Be reasonable and con- 
servative. 



THE FREE-LANCE VS. THE MAN IN PUBLIC LIFE. 

BY 

JOHN 8. FULTON, M.D., 
of Baltimore, Md. 

To the Editor of American Medicine: — Several weeks 
ago American Medicine called attention to the unfair 
advantage enjoyed by the critical free-lance, who may 
thrust at will against any and all official delinquencies, 
finding much sport and little danger in the exercise; 
because a public man risks his official character in all his 
acts, while the free-lance hazards nothing of like value, 
whatever else he may expose to counterattack. I am 
reminded of this admirable editorial by a more recent 
one (December 2, 1905) in which American Medicine 
comments on my reticence concerning Mr. E. T. D., of 
Baltimore, who says that he made unlawful use of 
money in order to get unlawful possession of the dead 
body of his child, unlawfully held by the health author- 
ities of a western city, where the death occurred on July 
13, 1904. After characterizing this " kidnap and ransom 
of a stranger's dead child " as a nameless and revolting 
crime of cupidity, you ask : "Is it not the business of 
any man, having knowledge of such an outrage, to give 
the matter full publicity?" The form of this inquiry 
suggests an affirmative answer, and I admit that the 
question does not present itself to me in another form. If 
every ethical question could be settled on general princi- 
ples, the affairs of this world would be greatly simplified. 
Only one of the accepted formulas seems to quite fit this 
case. I have done for the western health commissioner 
just what I should like him to have done for me if the 
situation had been reversed. Against the protest of Mr. 
D., the victim of the crime alleged, I have communi- 
cated the allegations to the head of the department im- 
plicated. The health commissioner thanked me for my 
interest in the matter, and said that he would call upon 
me later, if he should need more of the assistance which 
I offered. He has since retired from office, but the man 
expressly incriminated by Mr. D. retains his former 
position in the health department. Mr. D. wishes me 
not to expo.se the official who, he now says, simply 
accepted a gift from him. If I should declare freely all 
the details of Mr. D.'s statements to me, what crime 
would be uncovered? Bribe-taking? Or libel? Each 
of the principals in this scandalous affair knows that the 
evidence in my possession is unwillingly guarded, and 
both of them know that the prevailing practice in 
American mortality registration lends but a thin veil to 
their identity. Whose move is it? Not mine. 



Larg'e Vesical Calculus — On January 1 the surgical 
staff of the Cambridge, Md., Hospital took from the blad- 
der of a patient a stone weighing 4^ ounces, and about 
the size of a large duck egg. The patient is doing well 
and is now pronounced convalescent. This is believed 
to be one of the largest stones on record extracted from 
a person who survived the operation. Larger stones 
have been extracted but the patients have not survived. 






January 20, 19061 
Vol. XI, No. 3 J 



ACUTE OSTEOMYELinS 



[American Medicine 91 



ORIGINAL ARTICLES 



FOR EARLY 



ACUTE OSTEOMYELITIS: A PLEA 
DIAGNOSIS.' 

BY 

EMILi KING, M.D., 
of Fulda, Minn. 

Osteomyelitis Is an acute Inflammatory process affect- 
Bg bone and periosteum, and Is the result of hematog- 
enous infection. It occurs at all ages, but Is by far 
most common during Infancy and early childhood. At 
this time of life the tissues are in an undeveloped state ; 
the bones, and especially the epiphyses and'dlaphyses, 
are In the embryonal condition, their blood supply is 
superabundant, while the power of resistance to bac- 
terial infection is low. The disease attacks most fre- 
quently the femur, tibia, long bones of the upper ex- 
tremity, and then any other bone in the order men- 
tioned. 

As in disease, generally, several factors combining 
bring about abnormal conditions, and this is especially 
true of osteomyelitis. For convenience, I will divide 
the causes into predisposing and exciting. Of the 
former there are many, in fact anything which lowers 
vitality, and we may mention particularly measles, 
scarlet fever, typhoid fever, pneumonia, influenza, 
erysipelas, furunculosis, acute inflammatory affections of 
nose and throat, gastrointestinal disorders, and simple 
exposure to cold. The exciting cause is necessarily bac- 
terial infection. How the organisms gain entrance to 
the blood stream is at times impossible of detection, and 
having once gained entrance they may remain dormant 
until conditions are right for their development. Fre- 
quently there is a break in continuity, a scratch, punc- 
ture, or cut, in infants a septic umbilical cord, in older 
children and adults, perhaps carious teeth. Often no 
such apparent cause is found ; however, there is usually 
a history of some trauma, such as a contusion or sprain, 
and this trauma may be so slight as to escape notice. 

On bacteriologic examination of the pus. Staphylo- 
cocci aureus and albus and the streptococci are found most 
frequently ; rarely Bacillus pyocyaneus, the typhoid and 
influenza bacilli ; the latter only when osteomyelitis 
follows as a sequel to these diseases. 

The earliest symptoms are malaise, soon followed by 
a chill, or, in the very young, convulsions. The tem- 
perature rises rapidly, as does also the pulse-rate, which 
is out of proportion to the height of the fever, the respir- 
ations are increased, the tongue becomes heavily coated 
and the spleen enlarges. Emaciation is rapid, the 
patient assuming in a few days a decidedly typhoidal 
appearance. 

Pain is an early symptom, and is felt at the epiphys- 
eal lines or at the point where the nutrient artery 
enters the bone. It rapidly becomes severe, and is 
described as being of an excruciating and boring char- 
acter. It will increa.se in intensity until necrosis per- 
mits the exudate to escape into the surrounding softer 
tissues, thereby relieving pressure. Swelling is also apt 

' Read at a meeting of the Southwestern Minnesota Medical 
"Society, held at Sibley, Iowa, June 27, 1905. 



to appear early, and redness of the skin with local heat 
are present when the abscess approaches the surface. 
Naturally we observe also deformity with loss of func- 
tion, due to the swelling and contractures through nature's 
effort to place the aff'ected part in the easiest possible 
position. 

This disease is of an extremely variable type, some 
cases running a mild course with but little systemic 
involvement or severe local signs, while in others the 
system is overwhelmed by toxins, death resulting in 
from 24 to 72 hours, before a correct diagnosis can be 
made. 

I shall not consider the symptoms of the subacute 
and chronic stages. When this point is reached, the 
diagnosis is self-evident and probably severe damage has 
been done. Suppuration is usually present four or five 
days after onset, hence treatment to result in a quick and 
perfect recovery must indeed be prompt. 

Theoretically, the diagnosis in these cases should pre- 
sent no great difliculties, yet a study of the literature and 
my own experience show that these patients generally 
receive proper treatmjent only during the subacute and 
chronic stages, that they are treated for some other aff"ec- 
tion, and that the serious consequenees of delay are not 
properly realized. Indeed it is my opinion that an 
early diagnosis is often very difficult, that the attending 
physician may make an error even when alert, and hav- 
ing this very aff"ection in mind. Given a patient with 
a history of some slight injury, who may have had some 
recent illness and who suddenly develops fever with 
pain, the possibility of a developing osteomyelitis must 
be kept in mind and must be surely excluded. 

In seeking for the cause of the systemic involvement, 
our attention will, perhaps, be called to localized tender- 
ness. Patients old enough to walk are lame, or in 
infants handling causes pain. Very early in the history 
there may be no swelling, yet a careful palpation will 
locate a point of great tenderness. In long bones this 
point is at the epiphyseal line and the periosteum is 
found thickened. Very soon, however, edema of the 
subcutaneous tissues above or below the seat of infec- 
tion develops, and this sign is, by some very competent 
authorities, regarded as pathognomonic of this disease. 
This edema also affects the periosteum, and may be fol- 
lowed from day to day in its extension along the line of 
the shaft. Postural signs are also present, due to muscle 
spasm and contracture ; thus in the lower extremity the 
knee is flexed on the thigh and the thigh on the body, 
while the leg is adducted or abducted. Movement 
always increases the pain, thus I have seen children cry 
for half an hour after the most gentle examination. 
Deep fluctuation, due to pus beneath the periosteum, 
usually develops within a week. At this time the acute 
stage is at its height, the patient is greatly reduced in 
weight and presents a marked cachexia. The agonizing 
pains will now lessen, owing to the escape of the exu- 
date from its tense confinement in the shaft of the bone, 
or under the periosteum into the surrounding softer tis- 
sues, and anodynes may no longer be needed. Local 
swelling and fluctuation now become more marked, and 
the exudate finding its way to the surface may cause the 
discoloration of the skin already mentioned. If the 



92 American Medicine] 



ACUTE OSTEOMYELITIS 



r.riNUAKY 20, 1906 

LVoL XI, No. 8 



abscess is now opened or breaks spontaneously, great 
relief is aflforded, the appetite returns and a steady gain 
in strength and flesh sets in. 

The diseases most often causing errors in the diag- 
nosis of acute osteomyelitis are rheumatism, typhoid 
fever, deepseated cellular abscesses, sprains, erysipelas, 
tuberculous bone disease, scurvy, sarcoma, neuralgia, and 
growing pains. Of these, rheumatism and typhoid fever 
lead astray most often. 

Acute rheumatism, let us bear in mind, is rare in 
childhood; the systemic involvement is not so severe, 
there is not the rapid wasting nor the peculiar cachexia, 
acid sweats are the rule, while they are absent in osteo- 
myelitis. Acute inflammatory rheumatism is an arth- 
ritis, the joints are hot and tender, it is usually multiple 
and changes its location with surprising rapidity. Osteo- 
myelitis is, as a rule, confined to one spot, nor is the 
joint itself afl'ected during the early stage. The point of 
greatest tenderness is at the epiphyseal line or over the 
shaft of the bone. One point in differential diagnosis 
mentioned by many authors is that in osteomyelitis, tap- 
ping the bone in its long axis wil| cause intense pain, 
yet in one of my cases this test was negative at all times. 
From typhoid fever the differential diagnosis should be 
easier. This disease is also comparatively rare in chil- 
dren. It presents a longer prodromal stage than does 
osteomyelitis, the temperature curve shows a gradual 
rise, nor does the patient so quickly present a picture of 
severe illness. The aches and pains in typhoid fever are 
not so severe nor are they confined to one particular spot. 
During the second week the Widal test may be of value, 
but a test of far greater importance is a differential blood 
count. It has been shown that in septic infections there 
is a decided leukocytosis, the white cells ranging from 
18,000 to 30,000. In uncomplicated typhoid fever they 
are normal. Deepseated cellular abscesses, as a rule, 
develop slowly and do not give the marked systemic 
reaction noted in osteomyelitis ; they do not occur near 
joints, excepting the hip, nor along the shafts of long 
bones, but usually in more fleshy parts, the nates, 
axillas, and in children, the neck. In erysipelas the skin 
is intensely inflamed and is of a dark rose-red color with 
gloss; there is a distinct line of demarcation and the 
pain is of a burning character. Postural signs are also 
absent ; deep pressure does not cause such intense pain 
nor is the patient so ill. The other affections mentioned 
as simulating osteomyelitis do not, as a rule, develop so 
acutely and a thorough elicitation of the history and a 
careful physical examination will serve to prevent error. 
One other valuable aid in the diagnosis of these cases is 
the rontgen ray. Such an examination will show the 
thickening of the periosteum, the abscess formation, in 
later stages the osteoporosis and nature's efforts at repair 
by enclosing the dead bone with an involucrum, the pos- 
sible epiphyseal separation or more rare pathologic frac- 
ture. An early rontgen ray examination will certainly 
lead to more thorough diagnosis and efficient treatment 
by revealing the extent of the bony lesion. 

The complications of osteomyelitis are infections of 
joints by contiguity or through the blood and lymph 
channels, general pyemia, septic emboli and amyloid 
degenerations after long-continued suppuration. 



The prognosis as to life is good, the fulminating fatal 
cases being fortunately rare, but aside from this question 
of life or death it is rather pitiable. Too many such 
patients go through life as cripples with ankylosed 
joints, contracted muscles or shortened limbs, a sad thing 
truly when we realize that early diagnosis with prompt 
and thorough treatment will lead to quick recovery, a 
saving of much suffering and perfect restoration of 
function. 

I shall consider treatment but briefly, since my pur- 
pose is to call attention to the necessity of early diag- 
nosis. Medicinal treatment, aside from relieving pain, 
is worse than useless, since it leads to procrastination. 
The only proper measure is prompt operation, cutting 
down through the infecting focus, which can usually be 
determined as the point of greatest tenderness on palpa- 
tion or over the center of periosteal thickening, remov- 
ing the infection and establishing drainage. If the point 
of infection is removed, the severe symptoms at once 
subside and a rapid recovery follows. If pain and fever 
continue after an incision down to bone it is certain that 
the infection is still deeper. Prompt trephining into 
the marrow cavity must be done, for the patient is not 
relieved unless pain and high fever cease. The stage 
during which so simple an operation suffices is, however, 
short, since the shaft of a long bone may be entirely 
devitalized within 48 hours. 

The following cases are interesting from the diagnos- 
tic point, and are given because we should draw lessons 
from our failures as well as our successes. 

Case I. — F. H., male, aged 12 ; family and early 
history is unimportant. While working in a garden in 
April, 1901, he cut a gash on the outside of his right foot 
with a hoe. This wound healed slowly without medical 
assistance. July 20, he stubbed the right foot on a 
raised board on a sidewalk, jarring the leg rather 
severely. Immediately he felt a dull pain above the 
ankle externally which increased from day to day. 
Lassitude and fever developed and on July 24 medical 
advice was sought. On July 29 an incision was made 
externally just above the ankle, blood and serum only 
escaping. On July 31, the family requested counsel as 
the boy was getting steadily worse. The medical at- 
tendant refused to meet the counsel chosen and retired 
from the case. At this time I was asked to take charge 
of the case. The boy had a high fever, heavily furred 
tongue, the leg was edematous from the toes to above 
the knee. Deep fluctuation was present below the knee 
on the outside. The pain in the tibia was very severe 
and the wound made two days before was dry and clean. 
I suggested immediate operation to which consent was 
reluctantly given by counsel on the plea that the point 
of infection could not be determined. I made an in- 
cision just below the knee down to the fibula and tibia, 
serum and some flocculent pus escaped. The periosteum 
was but little thickened, no denuded bone could be felt. 
Drainage was inserted and we decided to await develop- 
ments. The pain was not relieved nor was the patient's 
condition otherwise changed. On August 2, the operative 
Wounds began to discharge bright yellow pus freely and 
the next morning a small abscess was discovered on the 
left anterior superior spine of the ilium which was at 
once incised and packed with gauze. Numerous small 
abscesses now developed in quick succession over bony 
points such as the wrists, elbows and costal cartilages and 
one, rather interesting, over the hyoid bone. The boy 
died August 26, from exhaustion due to general pyemia. 
I doubt if any operative interference would have saved 
his life when I first saw him as sepsis was very likely 



January 20, l%6n 
Vol. XI, No. 3 J 



ACUTE OSTEOMYELITIS 



[Aherican Medicinb 93 



already general. I .should, however, have insisted on 
trephining into the tibia; pus would certainly have been 
found. 

The case teaches that a more extensive operation is 
often necessary than seems apparent and that the search 
for the infecting focus must be continued from day to 
day if the symptoms do not subside. 

Case II. — M. R., female, aged 4. This girl was 
brought to me on September 23, 1902, with a history of 
a fall a few' days previously. She was bright, not 
feverish, but refused to have her leg touched. I placed 
her under moderate anesthesia and found a slight thick- 
ening at the epiphyseal line below the right knee. There 
was a little localized swelling. In view of her good con- 
dition and the reported accident I made a diagnosis of 
epiphyseal injury, applied a long splint to the outside of 
the leg to secure rest and a lead and opium lotion over 
the seat of injury. She was taken home with the promise 
to keep me informed of her condition. I heard nothing 
of her for 10 days. Her father then informed me that 
she was very ill, had much fever and great pain. His 
reason for not reporting her condition as agreed upon 
was the fear of expense and his belief that she would be 
better every day. I found her in a typhoid condition, 
high fever, moaning with pain. Her leg was edematous 
from toes to hip. Even at this time her parents were 
opposed to operative interference. I succeeded in get- 
ting permission to open the abscess only by threatening 
to withdraw from the case. The abscess extended from 
the knee to the ankle. No denuded bone could be felt, 
but I cut through the periosteum and then inserted 
gauze packing into the wound. Her parents refused 
permission for another visit unless she should get worse, 
even after ray explanation of her serious condition. A 
month later her father reported her asbeing'much better 
and paid my bill. From other sources I learned that she 
still has a discharging sinus at the present time. This 
case I frankly misunderstood, an incision when I first 
saw her would have cured her quickly. 

Case III. — T>. B., male, aged 12. There is a history 
of tuberculosis in grandparents on both sides, though 
parents, uncles, and aunts are all healthy. He is small 
for his age, delicate in appearance, yet has always had 
good health, except occasional joint pains, which his 
parents called rheumatism. Late last November he had 
a mild attack of measles, which kept him from school a 
week. About December 20, he sustained a small 
abrasion over the right patella and an injury to his 
right wrist, in consequence of a game of leap frog. He 
skated every day, and was more or less exposed to the 
cold, up to January 1, at which time he began feeling 
badly, and pains appeared in his right thigh. I saw 
him on January 4. His temperature was 103.5°, pulse 
140, tongue furred. There was great pain in the muscles 
on the outside of the right thigh and there was moderate 
swelling from the knee to the hip. There was a slight 
enlargement of the right ulna an inch posterior to the 
styloid process. This was only slightly painful to 
pressure. On the right patella, there was a dry scab, 
around which the skin was normal. My diagnosis was 
either .septic infection or rheumatism. Two days later 
his condition was practically unchanged, though the 
pain now included the knee-joint. His urine was high 
colored and very acid. Tapping the heel smartly did 
not increa.se the pain in the leg. Palpation seemed to 
sViow the pain to be located in the muscles on the out- 
side of the thigh only, and I now assumed his sickness 
to be rheumatism and treated accordingly. Two weeks 
later the pain got much better, but the leg became 
swollen also on the inside. About February 1, I began 
to suspect my diagnosis and suggested calling counsel. 
On February 8, Dr. Thomas Lowe, of Pipestone, 
Minn., was called. On account of a misunder- 
standing as to the time of his visit I did not 



see the patient with him. His conclusion was that 
the boy had an abscess, probably of tuberculous origin. 
I suggested immediate operation, which counsel declined 
to sanction. At this time emaciation was marked, the 
thigh was enormously swollen. The ulnar enlargement 
had increased somewhat but caused no pain. The leg 
had become everted and the knee was flexed. He did 
not have much pain and craved food. We put him on 
a full diet with codliver oil. He gained in weight and 
appearance. The swelling of the thigh receded slowly 
during the next six weeks. Now fluctuation became 
marked at the perineum, and the boy being much 
stronger we decided to open the abscess. I made a two- 
inch incision, five inches below the perineum, and found 
a pus cavity which extended down behind the femur to 
the knee. The femur was carious. While exploring 
the cavity digitally a second abscess was ruptured ; this 
one surrounded the upper epiphysis and accounted for 
the swelling at the perineum. An involucrum had not 
formed around the femoral shaft, so we simply drained 
the abscesses. At this time the leg was everted to a 
right angle with the body. The hip-joint was immov- 
able. After this operation he gained very rapidly in 
flesh and strength. His temperature, which had varied 
from 99° to 102° during late February and March, re- 
mained below 100°. I examined him June 26. Found 
him walking with crutches. The leg has come almost 
into a straight line so he can bear weight on the toes. 
There is considerable motion in the hip-joint and he 
looks as well as he did last autumn. At the wrist there 
is only a slight enlargement, which I believe to be cal- 
lus in a greenstiek fracture. The involucrum around 
the shaft of the femur is strong and extends along its 
entire length. This is a case of osteomyelitis of the 
femur without tuberculous infection. The abscesses 
formed at each epiphysis and an early operation would 
have saved the boy much sufitering and a possible partial 
crippling. 

In a 12 years' experience in the practice of medicine 
I find that most of my errors in diagnosis are made in 
cases that run an atypic course. By that I mean that the 
symptoms are not well marked of the disease I have in 
mind or that treatment does not give the expected relief. 
This last case was apparently not as acute as osteomye- 
litis usually is, and the pain being referred entirely to 
muscles I was misled into thinking I had rheumatism 
to deal with. 

In conclusion I beg to say (1) that cases running an 
atypic course, or not responding properly to treatment, 
should put the physician on his guard that he may revise 
his diagnosis ; (2) that greater care should be exercised 
in the examination of patients ; (3) that the early diag- 
bosis of osteomyelitis is not always easy, yet can usually 
be made by bringing to aid all modern methods, such as 
a blood count and the rontgen ray ; (4) that early proper 
treatment will save much suffering, possibly lifelong 
crippling, and perhaps life itself. 



The British 3Iedical Journal states that the trustees of 
the Pilkington Cancer Research Fund are about to 
appoint a graduate in medicine, or other qualified 
person, to carry out a research into the cause, prevention 
and cure of cancer, under the supervision of the profes- 
sors of general pathology and of systematic surgery in 
the Victoria University of Manchester (Professor Lor- 
rain Smith and Professor G. A. Wright). The appoint- 
ment will be for one year, but may be renewed for a 
further period of one or two years, and the holder of the 
post will receive an income of £300 per annum with a 
grant for laboratory expenses. 



94 Amkbican Mkdicinkj 



MEDICINAL PLANTS OF ANGOLA 



[J AN OAKY 20, 190fl 
Vou XI, No. 3 



SOME MEDICINAL PLANTS OF ANGOLA, WITH OB- 
SERVATIONS ON THEIR USE BY NATIVES OF 
THE PROVINCE. 

BY 

P. CREIGHTON WELLMAN, M.D., 
of Angola, Africa. 

(Published under the auspices of the American Society of Tropical 
Medicine.) 

The study of the plant life of Angola must remain 
forever linked with the name of Friedrich Welwitsch, 
whose discovery of that extraordinary plant WelwiUchia 
mirabilis, Hook, fll., has made his name familiar to 
every botanist and over whose tomb have been placed 
the just words : ^^ Florae, Angolensis investigalorum prin- 
ce/)s." 

Dr. Welwitsch mentioned and described a number of 
medicinal plants in his published and manuscript writ- 
ings, but having slight acquaintance with the different 
Bantu dialects of Angola, his notes on the native names 
and medical uses of the same are frequently vague and 
contain erroneous statements. Examples might be 
cited of Bantu names of plants with meanings such as 
"grass," " small grass," " tree from the water," " twig 
from the jungle," etc., and such mistakes have been 
perpetuated by writers following him. 

In the intervals of some pathologic studies under- 
taken in the colony in question in 1896, 1899, and 1903, 1 
have been able to identify a few species commonly used 
by the natives for medicines and to collect trustworthy 
information regarding the manner in which they are 
applied. All mention, however interesting, of plants 
other than those commonly employed as native reme- 
dies has been excluded. The plants used in treatment 
consisting of fetish rites only, have likewise been 
omitted. It must also be borne in mind that these notes 
apply to the bush natives of Bih(5, Bailundo, and Andulo, 
with their contiguous tribes, and do not include the half- 
civilized coast blacks. This study does not pretend, 
therefore, to be part of an academic discussion of Ango- 
lan flora, for which I have neither the requisite leisure 
nor experience, and consequently I have omitted descrip- 
tions of the plants which may be easily looked up in 
Oliver's " Flora" or in Bentham and Hooker. 

It need hardly be pointed out that many of the sub- 
stances imagined by the Bantus to possess therapeutic 
value are of feeble effect or inert ; yet as the object of 
this paper is not to set forth what the natives might use 
as medicines but to state what they do use, I have 
thought it best to make the list as complete as possible. 
I have grouped the plants under their natural orders. 
The vulgar names (without which such a study is useless 
and can neither be added to nor criticized) are in the 
Umbundu dialect, the language of the Bih6ans, Bailun- 
dos, and Andulos, with their allied tribes, and have been 
obtained at the expense of some time and trouble. I 
append a short bibliography, which will be useful to any 
one' who may be further interested in the subject. 

PHANEBOGAMIA, DICOTYLEDONS, RANUNCULACEjE. 

Utendulu, Clematis villosa var. scabiosifolia, De C. 
The roots are boiled, mashed up, and applied to the skin 
as a remedy for "Onjuaya," a term which literally sig- 



nifies itching, and refers to cutaneous pruritus from 
almost any cause. 

A NONAGED. 

Olumepe, Monodora angolensis, Welw. Fruit eaten 
for pains in the bowels. Sometimes boiled and its juice 
drunk for the same purpose. 




Fig. 1.— Scene in southern Angola showing Candelabra 
Euphorbias. 

BERBERIDACE.E. 

Okafiaunau, Podophyllum sp. Boots eaten raw in 
the treatment of dysentery. 

NYMPHACE^. 

Evonge, Brasmia peltata, Pursh. The whole plant 
is pounded up and applied raw as a poultice in neuralgic 
pains and in paralyses. 

POLYGALACE^. 

Utata, Securidaca longipedunculata, Fres. A weak 
infusion of the rootlets is used to cure "olosiDga,"a 
somewhat indefinite term which indicates pains in the 
chest, shoulders, etc. The inner bark of the root con- 
tains an active poison which is one of the ingredients of 
the poison test as employed in Angola. Four gm. of 
this bark boiled in 30 cc. of water and given to a large 
female mandril {Oynocephalus sp.) produced death in 48 
minutes. The roots hashed up are used by native 
women to commit suicide. The method, as described 
by them, consists in placing small quantities in the nos- 
trils, ears, armpits, and vagina; but in the one case 
which fell under my notice an emetic brought up gener- 
ous quantities of the drug from the stomach. The roots 
when cut or bruised give off a strong odor of Oleum 
gaultherice. » 

TAMARISCINE^. 

Oluvili, Tamarix arlioulafa, Vahl. Twigs pounded 
up raw and applied locally as a remedy for scabies. 

MAIA'ACE^E, 

Ocingombo, Hibiscus esoulentus, L. The mucilag- 
inous juice of the half-ripe pods is dissolved in water by 
gentle heat and drunk as a demulcent in coughs. 

Ukua, Adansonia digUata, Juss. This tree is usually 
found just outside the district in which I made this 
study, but as the natives procure and use its fruit, etc.. 



January 20, 190«n 
VOL. XI, No. 3 J 



MEDICINAL PLANTS OF ANGOLA 



[American MEDicrNH 95 



I include it here. A decoction of the seeds is drunk 
after fevers as a tonic stimulant. The pulp of the fruit 
is also eaten raw to cure diarrhea. 

Utele, Oossypium sp. Smoke of leaves inhaled as a 




Fig. 2. — Tamarix articulata, Vahl. 

remedy for headache. The leaves are also dried by the 
fire and the odor inhaled for coryza. 

STERCULIACE^. 

Ocitutu, Xeropelalum cuanzeims, Welw. In case of 
childbirth with retained placenta the vulva is bathed 




Fig, .'i.— West African Malvacece growing in a swamp. 



with a decoction of the leaves. It is also thought to be 
good in cases of edema of the external genitals. 

bubsbrace.;e. 

Umbafu, Garanarium edule, Hook. f. The habitat of 
this tree, like A. digitata, lies, strictly speaking, without 
the region under consideration, but since the products of 
the tree are used by the natives I have observed, I in- 
clude the following note. The resin is applied as a 
balsam to sores and ulcers, and its inhaled perfume is 
said to relieve headache and accelerate difficult child- 
birth. The oil is esteemed as an application for strains 
and bruises. The powdered bark is also .sometimes used 
in the treatment of ulcers. The seeds are often worn 
round the neck as charms. 

dodonace^t:. 

Utola, Ptaeroxylon utile, E. et Z. Leaves chewed up 
and placed around joints to relieve malarial pains. Bark 
scraped fine and applied in the same way. 



'^ ^, 


~^W 


'.J jT^ 


p^^ 


./ . 




-^'•^'"y^& 




^^te 


^^&^ 






ti^ 


^m 


^§ 


/^ P'^-f *\ / _ ■ -Jl 






^^m 


f^ v^- 






^^Hr^^? 


^^T^ 


^»K./' , 


"':• 1.,; 77'?|^ 




h1 t..w 




"t^^;- ■- 


mk 






m 


bH 



Fig. 4. — Adaiwonia digitata, Juss. 
ANACARDIACEJ5. 

Ohumbi, Odina acida, Welw. Bark pounded up, 
boiled, and applied to freshly made wounds. 

Usondanduva, Pseudospcmdias microoarpa, Engl. 
Powdered bark snuffed up the nostrils in case of epis- 
taxis. • 

liEGUMINOSyE. 

Onjilasonde, Pterocarpus erinaceus, Poir. In case of 
neuralgias and muscular pains, the skin is scarified and 
the inner bark of the tree hashed up and boiled is 
applied. The bark is very astringent and is used by the 
Boers for tanning leather. The gum which exudes 
when the tree is cut into, closely resembles the gum 
kino of commerce. 

Ohula, P. tinctorius, Welw. .Juice of bark given to 
babies who refuse to eat when being weaned. 

Omanda, Berllnia pcmlcukUa, Benth. Steam from 
infusion of bark used, along with various fetish cere- 
monies, in the treatment of nervous disorders. 

Omue, li. uriffolensui, Welw. The bark is pounded 
up, boiled, and the mess taken internally for diarrhea. 



96 A.jtKBioAN MKDionral 



MEDICINAL PLANTS OF ANGOLA 



rjAsaARY 20, 1906 

LVOL. XI, No. 3 



Okalembe, Tephrosia vogelu, Hook. f. An extract of 
the leaves is used (just in what manner I cannot learn) 
in the treatment of obscure diseases, accompanied by 




Fig. b.—Pteroaarpus erinaceus, Poir. 

dropsy. This is the shrub which is used to poison fish 
in rivers and streams. It is also mixed with f6od and 
employed to kill enemies. 

Okapilingau, Burkea qfricana, Hook. The bark, 




hematuria from bilharziosis or other cause. Used in 
different ways, it is a favorite remedy for sexual dis- 
orders. 

Ombambu, Erylhrophloeurn yuinmse, Don. The bark 
is used for some types 
of heart disease, but I 
have not been able to 
get details. This is 
the tree which fur- 
nishes the principal in- 
gredient in the poison 
test of the negroes 
throughout tropic Af- 
rica. The bark, which 
in small doses produces 
vomiting and purging, 
has been tested physi- 
ologically. If pow- 
dered and inhaled it 
causes sneezing. The 
aqueous extract when 
injected under the skin 
of animals produces 
vomiting, irritates, and 
finally paralyzes the 
vagus nerve, causing 
the heart to slow, and, 
in larger doses, to stop. 
The limbs seem to 

become paralyzed before death as the victims of the 
poison test fall to the ground shortly after drinking the 
mixture. As I have fully described in another publica- 
tion the manner in which this extraordinary custom is 
carried on, I shall not repeat it here. 




Fig. -i.—Berlinia angolensis Welw. 



Fig. ii.—Berlinia paniculata, Benth. 

macerated in a little water, is inserted by the women in 
the vagina as an aphrodisiac. Water in which the bark 
has been soaked is held to be valuable medicine for 




Fig. S.— Burkea iifHcana, Hook. 

Ocati, Cassia occidenialU, L. Boots boiled in water 
and the decoction administered as an anthelmintic. 

Ososo, mtuda abyosinica, Stend. leaves pounded 
up and applied raw to limbs swollen from any cause, but 



JANnABY W, 19061 
Vol. XI, No. 8 J 



MEDICINAL PLANTS OF ANGOLA 



[AHEBICAN MEDICINK 97 



generally attributed to witchcraft. The ashes from the 
burnt leaves are applied to the umbilicus of newborn 
children. 

Usonge, Albizzia anthdminlica, A. Brogn. Generally 
esteemed a specific for the diseases of domestic animals 
(dogs, etc.). The roots are also boiled to make a mouth 
wash for ulceration of the gums, sinuses from decayed 
teeth, etc. It is also used in some way I cannot learn 
for headache and neuralgia. 

Okangato, Acacia rejiciens, \Vawra» Leaflets boiled 
with salt and given for dysentery. 

ROSACJE.F,. 

Usia, Paranarium mobola, Oliv. The bark is em- 
ployed in debility from any cause as a stimulant and 




Fig. 9. — Paranarium mobola, Oliver. 

tonic. The usual method is to boil the bark and inhale 
the steam. 

MYRTAC?:.K. 

Ongayawa, Psidium up. Infusion of leaves employed 
as an internal astringent in diarrhea. Green fruit eaten 
for same purpose. 

Ulembaputu, Eucalyptus spa. Decoction of leaves 
drunk by natives for intermittent fever. 



COMBRKTACE.K. 



Ungolo, Terminuliu angolensis, Welw. 
roots considered a remedy for diarrhea. 



Inner bark of 



RUBIACIE^. 

Ocilavi, Gardenia jovis-tonantis, Hiern. Bark some- 
times used as a bitter tonic. As its names implies, it is 
believed to be a charm against lightning. 

VERBENACK.K. 

Usilusilu, VUex sp. The leaves are boiled, pounded, 
Bd applied to the abdomen for colic. The plant is also 
. in some form to treat conjunctivitis. 

l.AlilAT.E. 

Ondembi, Aeolanthus sp. Applied as a stimulating 
oultice in anemia and cachexia. 
Okateterabula, Tinnea antiscorbuta, Welw. This 
name was first given me for a mint {T. antiscorbuta), the 



leaves of which are boiled in water and used as a mouth 
wash, but in another part. of the country the term 




•'*i^- 



a" -t^^K: 



smM 






Fig. 10,— Gardenia jovis-tonantia, Hiern. 

" Okatetembula " is used to indicate Uapaca beitguel- 
lensis, q. v. 

composite:. 

Ocisekua, Tarchonanthus camphorutus, L. Used in 
malarial fever. Bark ground up and drunk in decoction 
and odor inhaled. 

Kayelelindi, Calendula, sp. Leaves boiled and applied 
as a poultice to strains, bruises, etc. 

PLUMBA(iINACE^:. ' 

Nakanganga, Plumbago zeylaniea, L. The roots are 
applied to the skin as a blister, and small quantities are 
also placed in the cavities of decayed teeth to destroy the 
nerve. In Bih6 the name " Nakanganga " is applied to 
a small leguminous shrub which I have never seen 
described. It is very poisonous, and I know of one 
instance in which a man accidentally killed his child by 
the administration of a small quantity of the leaves 
(mistaken for another plant) steeped in water. 

EBENACE^. 

Owelele, 3faba mualala, Welw. Infusion of leaves 
and twigs used as an anthelmintic. 

APOCVNACE.E. 

Ocimblnga, Strophanthus sp. The milky juice (which 
was formerly used to poison arrow heads) is applied to 
sores. The fresh exudation from the roots is used. 

I^OCiANIACE.K. 

Upole, Strychnossp, Roots boiled, mixed with maize 
or millet beer and drunk for pains in the bowels. 

t'ON VOLV U LACE^E. 

Olucatu, Cuscufasp. Used for muscular pains. Boiled 
and drunk ; also applied locally. 



98 American MbdicikkI 



MEDICINAL PLANTS OF ANGOLA 



CJanuaky 20, 1906 
VOL. XI, No. 3 



SOIjANAOEjE. 

Alulangue, Atropa spr The fruit pounded up and 
mixed with salt is applied locally for the "goat itch," 
which Ifills goats unless treated. The fruit is also cut in 
two and applied to the body in case of severe pain in 
persons suffering from malaria. 

Olundungu, Capsicums]). Sometimes given to expel 
worms. 

Ekaya, Niootiana tubacum, L. Is almost universally 
used either smoked or in the form of snuff. It is never 
chewed. Medically it is put on cuts and fresh wounds 
and the roots used in the treatment of trachoma. 

CIIEXOI'ODIACE.E. 

Etiambulu, Chenopodium ambrosioides, L. This is 
the great panacea of the partially civilized blacks and 
half castes. Boiled and drunk for headache, pains in 
the chest, stomach, etc., also for worms and various ail- 
ments. The bush natives are coming to use it more 
than formerly. 

EUPHORBIACEJE. 

Omolo, Ricinus communis, Miill. The oil is used in 
the treatment of "ukau," a skin disea.se resembling 
eczema. The leaves are pounded up and inserted in the 
vagina to make a retained placenta come away. 

Osoma, Euphorbia rhipsaloides, Welw. The milky 
juice mixed with water is taken as a demulcent and 
expectorant in chest diseases. The terminal joints of 
the branches are also eaten raw for the same purpose. 

Ocimbolo, Jatropha curoas, L. Seeds chewed up and 
swallowed as a purgative. 

Ombula, Uapaca benguelknsis, Miill. Infusion of 
bark and leaves used for nosebleed, being snuffed into 
the nostrils and held in the mouth. Also as a mouth 
wash for ulceration of the gums. Diarrhea is likewise 




Fig. 11. — Uapaca benguellensis, Miill. 

said to be cured by it, the infusion being drunk for this 
purpose. 

CANNABINE^. 

Epangue, Gannabis sativa, L. Hemp smoking is 
common. Medically the effects are held to be those of a 
tonic. 



AETOCARPE^. 



Ulemba, Ficus psilopoga, Welw. The leaves and 
bark are made into poultices for pains of almost any 
description. 

Ukuyu, F. iiMcuso, Welw. Different parts of this 




Fig. 12. — Ficus psilopoga, Welw. 

tree are used as ingredients in mixtures used to treat 
various complaints supposed to be due to witchcraft. 

MONOCOTYLEDONS, GRAMINE.E. 

Owangu. This is a general name for grass. Species 
of Eragrostis, Setaria, and Phyllorachis, which are used 
in women's diseases, but more especially in fetish rites. 
A coarse grass (which I am unable to determine), called 
"Ohotahota," is burned and the smoke inhaled for 
headache. A grass of which I have not seen the flower 
or fruit, is used in stomach troubles. The root is the 
part employed. I have also had specimens near Panni- 
cum and Pusjmlum brought to me, but with very vague 
information as to their medical uses. Grasses being 
difficult to recognize, the above list is by no means 
complete. 

CYPERACE.E. 

Osoka, Cyperus sp. Roots eaten raw as an anthel- 
mintic. 

Ocimbu, Papyrus antiquorum, L. Ashes mixed with 
other medicines to increase their efficiency. Several 
other sedges are used in witchcraft and fetish rites. 

I.ILIACE^. 

Ocandala, Aloe sps. The thick, fleshy leaves are 
chewed and swallowed to produce catharsis after over- 
eating, and the juice is also employed in the treatment 
of sores. 

Onjelele, Asparagus sp. {? raceniosus). Supposed to 
be a strengthening application to the body in cachexia. 

Ombungululu, A. africanus. Infusion drunk to cure 
pains in the chest. 



January 20, 19061 
Vol. XI, No. 3 J 



MEDICINAL PLANTS OF ANGOLA 



AMERICAN MBDICINK 99 



AROIDE^. 



Evongevonge, Richnrdia africana. Leaves and flow- 
ers mashed up and applied to paralyzed limbs. 




Pig. 13. — Richardia africana growing in swamp. 
PALMACEvE. 

Ondende, Elaeis guiiiensis. The oil is applied to 
sores. 

Ocisome, Melroxylin sp. Is used medically, but just 
how I cannot learn. 

cokvphine.t;. 

Okasalala, Phoenix npinosa. Ashes used in treating 
weakness of old age. 

IKIDACE^. 

Sipesipe, Gladiolus sp. Roots boiled, mixed with 
meal, and taken for cystitis or any other bladder trouble. 

BBOMELIACE^,. 

Oclteke, Amomum sp. Seeds eaten for abdominal 
pains. 

Ovomomis, Cbstus sp. Used same as preceding. 

SCITAMlNEiE. 

Ucalo, Carina sp. Used same as two preceding, 

CRYPTOGAMIA, POLYPODIACEJl':. 

Ocinjamba, Pohjpodlum sp. Boiled and steam used 
as vapor bath in hyperpyrexia. 

oriii()(;i,ossAC'K.E. 

Ocinyene. Roots used like ergot to hasten childbirth 
or procure abortion. 

Ocusitu, Adianlum sp. Used like foregoing. 

A glance at the preceding review shows (1) the bush 
natives of west Africa use a large variety of plants as 
medicines ; (2) as a rule they have a separate remedy 
for each disease ; (3) their internal remedies are almost 
exclusively administered in the form of decoctions or 
Infusions ; (4) they have faith in many inert substances. 
The study of the plants used by a savage people like 



those here observed throws an interesting sidelight on 
the evolution of materia medica and therapeutics. 

A study of this kind must necessarily always remain 
incomplete. Since writing most of the foregoing notes, 
a sedge, a mint, two fungi, an orchid, an alga, a species 
of Spondias, several UmhellifercE, and three additional 
Gompositce, all purporting to possess medicinal virtues, 
have been brought to me. These, with other new 
material, I hope to discuss at some future time. Only a 
few of the diagnoses of the plants mentioned in the fore- 




Fig. 14. — Caunas growing in jungle. 

going list have been confirmed by specialists, but I hope 
the errors found will be inconsiderable. 

The illustrations are from photographs taken espe- 
cially for this paper by Mr. W. E. Fay, B.A., with the 
exception of Figs. 3, 12, 13, and 14, which are from 
photographs kindly given to me by Mrs. E. D. Wood- 
side. 

REFERENCES. 

Plantas Uteis da Africa Portugueza, 1884. .Tourn. Linn. Soc, 
iii, pp. I.tO-157 ; v, pp. 182-187. 

Flora of Tropical Africa, Oliver, 1887. Journ. Bot., xxxiii, 
pp. 70-79 and l.iO-141. 

('atalogue of Welwitsch's African Plants, Hiern, 180(i. 

Apontamentosphyto-geographicas, etc. Welwitsch in Ann. 
Conselho Ultramar, Lisbon, No. Tm, December, isr)8. 

Synopse explicativa das amostras de madeirnH e drogas 
medicinaes, etc. Welwitsch, p. .">(i, et seq., Lisbon, 1862. 

Oevera Planlarum^Jientham and Hooker. Parts II and III. 
1.86.5-1867. 

As exploracoes phyto-geographicas da Africa Tropical. 
Gomes in Jorn. Science, Lisboa, No. xiv, pp. 151-1!«, Lisbon. 
1873. 

Notlcia de alguns produetos vegetaes importantes, etc. 
Ficalho in Jorn. Scienc. Lisboa, No. xxli, pp. 07-109, Lisbon, 
December, 1877. 



Extremely Jjong Pregnancy. — J. Arthur I^amb 
gives an account of a case of pregnancy which lasted, 
dating from the last menstruation, 339 days ; and dating 
from the last coition, 313 days. These data seem to be 
well fixed. The cause attributed by him was a cranial 
deformity of the fetus, interfering with prompt natural 
delivery, the exact nature of which is not stated, though 
it is said that the brain was exposed, giving the sugges- 
tion of a breech presentation. It would have been 
interesting, he remarks, to have known how long this 
case would h^ve gone had not quinin been given to 
cause uterine contractions.— .7oMr«c// A. M. A. 



100 Ambbican MkdicinbJ 



TREA.TMENT OF ANAL FISSURE 



CJAH0AKY 20, 1906 
VOI,. XI, No. 3 



ETIOLOGY, SYMPTOMATOLOGY, AND TREATMENT 
OF ANAL FISSURE.' 

BY 

HERMAN A. BRAV, M.D., 
of Philadelphia. 

A typical anal fissure may be described as a linear 
ulcer at the mucocutaneous junction of the anus, giving 
rise to intense suffering on defecation. It is usually 
situated just within the verge of the anus, at or near the 
posterior commissure, but may occur within the Inner 
surface of the external sphincter and may be located at 
any part of the anus. A fissure situated anteriorly is 
more often encountered in women, owing to the fact 
that the overstretched condition of mucous membrane 
of the anus is apt to tear during parturition and leave 
behind one or more slits or clefts, the socalled fissure or 
irritable ulcer of the anus. The passage of hard feces 
over the delicate mucous membrane may readily cause a 
tear. 

It is possible also that the constant presence of a dry 
mass of feces in habitual constipation interferes with the 
secretion of the glands of the rectum, rendering the 
mucous membrane dry and inelastic, and therefore more 
liable to be lacerated during its passage through the anal 
orifice. 

Be.side constipation, fissure may be due to congenital 
narrowing of the anus, eczema, and herpes anl, foreign 
bodies which have been swallowed and passed through 
the rectum, polypus, uterine displacements, dysentery, 
syphilis, and the tuberculous diathesis. Occasionally 
fissure is met in patients who have practised pederasty 
or rectal masturbation. The frequent and careless intro- 
duction of the syringe nozle when giving enemas may 
also induce a fissure in ano. Quenu and Hartman 
believe that a tendency to piles is the real cause of fissure. 
Boyer, on the other hand, considers the spasmodic con- 
traction of the sphincter muscle the cause of the disease. 
Ball, of Dublin, is of the opinion that the majority of 
fissures are produced by the tearing down, during a hard 
passage, of the lateral attachments of one of the valves 
of Morgagni, which can be demonstrated at the lower 
end of the fissure as a hypertrophied and edematous fold 
of skin, constituting the socalled sentinel pile. It is 
true that this condition is found in some cases, but I 
failed to find it in the majority of cases. It is therefore 
evident that fissures are the result of tearing of any 
part of the mucosa. Fissure is an affection of adult life, 
but may also occur in children. I have seen several 
cases in young children. Allingham, Curling, Mathews, 
Quenu, and Hartman mention cases in infants in arms. 
Recently I saw such a case with Dr. Hofkin, in a child 
of about 18 months, in which two fissures were present. 
Jacobi thinks fissure of the anus a much more common 
affection in children than is generally supposed, and 
believes that many fretful children who sleep badly and 
cry constantly, and often present symptoms simulating 
those of vesical calculus, really suffer from fissure of the 
anus. Fissure is probably more frequent in females 
than in males. This is probably due to the fact that the 

' Read before the Northern Medical Association, February 
24, 1005. 



former are more apt to lead sedentary and indoor lives, 
and are therefore more prone to suffer from constipation, 
which is, beyond doubt, the main cause of fissure. 
Furthermore, parturition has some influence in its 
causation. 

Symptoms : It is safe to say that no other wound 
inflicted upon a person produces such intense suffering 
and reflex manifestations as a typical flasure. 

I have seen men and women entirely incapacitated 
by this insignificant lesion. The pain during and for 
some time after a stool is so severe that patients will, as 
a rule, defer the act of defecation for days and in some 
instances for weeks in order to escape it. In the early 
stage of the disease, pain is not so severe and does not 
last long, but as the wound is irritated, and perhaps fur- 
ther torn by each pa.ssage, the pain increases in severity 
and duration. The patient now complains of a burning, 
shooting, and throbbing sensation within the anus, ac- 
companied by an intense itching. The pain may persist 
for one-half hour to six hours or longer, after the act of 
defecation. The exposed nerve filament in the floor of 
the fissure calls forth undue and excessive action of the 
sphincter, and this spasm by compressing the wound 
aggravates the pain. 

The stool may contain a few drops of blood, especially 
when the actual tearing takes place, but profuse hemor- 
rhage is a rare occurrence, unless complicated by piles. 
Occasionally a slight discharge of mucus or pus is notice- 
able. Pruritus is one of the most annoying symptoms, 
and is sometimes more difficult to endure than the 
sphincteralgia. The patient when asked to force the 
anus outward will find it impossible to do so, owing to the 
spasmodic contraction of the sphincter and the levator 
ani. Flatulence is present in nearly all cases for the 
same reason. Often marked reflex symptoms are notice- 
able. The patient complains of pains in the loin over 
the crest of the ilium and sacrum, and down the backs 
of the thighs and calves, and this is frequently mistaken 
for sciatica. Occasionally attacks of retention of urine 
are present as a reflex accompaniment of anal fissure. 

Pain in the uterus, vagina, ovaries, and prostate is 
sometimes observed. To sum up, the most character- 
istic symptoms of anal fissure are : pain or irritation of 
the anus and paroxysmal contraction of the sphincters. 
While these symptoms may be considered as pathogno- 
monic of the disease, it is well to remember that without 
a local examination, comprising inspection and a digital 
exploration, it is not possible to reach a correct conclu- 
sion. The following case will show the absolute neces- 
sity of a local examination : 

Case. — B. C, aged 28, barber by occupation, came to 
my office complaining of pain in the rectum during and 
for some time after defecation ; he also saw blood in his 
stool and suffered from constipation. He had consulted 
a physician, who told him he had bleeding piles and 
treated him for that condition for about two months. 

In spite of treatment he grew gradually worse. The 
symptoms presented the characteristic symptoms of As- 
sure, and an examination revealed the presence of an 
abrasion just within the grasp of the external sphincter. 
A complete cure was effected by forcible divulsion. 

A digital examination is always required to ascertain 
whether or not there are other morbid conditions com- 



January 20, 19061 
Vol. XI, No. 3 J 



BRIEFS ON GENITOURINARY SURGERY 



lAMEBICAN MEDICINlt 101 



plicatiug the fissure. The following conditions are often 
encountered in conjunction with fissure: polypoid 
iiTOwths, piles, blind internal fistula, and submucous 
abscess. Not much pain is caused by the passage of the 
finger into the rectum if gently introduced and passed 
well against the opposite side from where the fissure is 
located. 

The recognition of such complications is very impor- 
tant, because, unless they are removed simultaneously 
when the fissure is operated upon, the healing will be 
much slower and a permanent cure improbable. The 
treatment is, as a rule, divided into the palliative and 
the operative. The palliative treatment is suflicient in 
most cases. It consists of measures for preventing con- 
stipation, observation of local cleanliness, and local ap- 
plications to the ulcer. As constipation is the exciting 
cause of fissure in the vast majority of cases, we must 
endeavor to regulate the bowels and secure at least, once 
in 24 hours, a soft motion. This can be best accom- 
plished by the administration of the fluid extract of 
cascara sagrada at bedtime. 

In cases of obstinate constipation, saline cathartics are 
indicated ; drastics, however, should never be employed. 
The injection of two ounces of olive oil at bedtime to be 
retained all night has an excellent local effect. The 
daily application to the ulcer of a .65 gm. (10 gr.) solu- 
tion of silver nitrate or a 20 ^ solution of ichthyol and 
an ointment containing opium and belladonna may be 
followed by a cure in cases of uncomplicated fissure, 
when the ulcer is small and not deep, and when there is 
no marked sphincteralgia present. If these measures 
fail, cauterization should be resorted to. A 20 % solution 
of cocain should be applied directly to the ulcer on a 
pledget of cotton, to reduce the pain accompanying and 
following this procedure, and the fissure is then 
thoroughly cauterized either with the electric or Paquelin 
cautery-point or with the solid stick of silver nitrate, or 
carbolic acid. I like the electric cautery knife and 
always employ it in preference. The operative treat- 
ment is the surest and quickest method of cure. Com- 
plicated cases of fissure and even simple ones, when 
there is much spasm of the sphincter, should be operated 
upon as soon as possible. There are several methods 
practised for the operative treatment of fissure, but all 
have the same object in view, namely, the causation of 
a temporary paralysis of the sphincter, placing the ulcer 
to rest until repair can take place. Stretching of the 
sphincter with incision of the ulcer or the socalled 
Beyer's operation is commonly practised by English 
surgeons. 

The French surgeons, on the other hand, practise 
stretching of the sphincter without incision of the ulcer 
— Recamier's operation. Gradual dilation may be prac- 
tised when the patient refuses to take a general anes- 
thetic, or when there is any contraindication to the 
administration of an anesthetic. This may be done 
with the fingers or with anal dilators. Local anesth&sia 
is required for this form of divulsion. Forcible dilation, 
however, under general anesthesia, is the best method. 
This can readily be done under nitrous oxid anesthesia. 
The method of operation I employ is divulsion with 
incision, trimming at the same time the indurated 



margin of the wound, and cureting the base. The after- 
treatment consists in keeping the bowels confined for 
three days, and after this time daily movements are 
secured by laxatives. The ulcer usually heals in about 
two weeks. 

In conclusion, I would emphasize that a local exam- 
ination is indispensable in a case of suspected fissure. It 
is better to refuse to treat patients who, from motives of 
delicacy decline a local examination, than to commit 
yourself to po.ssible errors. 



BRIEFS ON GENITOURINARY SURGERY. 
The Diagnosis of Incipient Genitourinary Tuberculosis. 

BY 

G. PRANK LYDSTON, M.D., 
of Chicago. 

Professor of Genitourinary Surgery and Syphllology, State University 

of Illinois ; Attending Surgeon, St. Mary's and Samaritan 

Hospitals. 

There is a marked parallelism in the difficulties and 
methods— to say nothing of the necessity — of an early 
diagnosis in pulmonary and renal tuberculosis. It is 
generally accepted that in by far the larger proportion 
of cases of tuberculosis affecting the genitourinary tract, 
tubercle bacilli are not discoverable in the urine until 
pronounced invasion of the tissues, and a certain amount 
of breaking down have occurred. This being the accepted 
idea, it is obvious that in very many instances the golden 
opportunity for successful treatment is lost. We can 
imagine how disastrous it would be for the welfare of 
our patients were it only possible to make a diagnosis in 
pulmonary tuberculosis after breaking down of lung 
tissue has occurred. 

Clinical experience has convinced me that greater 
care in diagnostic methods will enable us to discover 
genitourinary tuberculosis in its incipiency much more 
frequently than is ordinarily supposed. The point 
which I desire to make will be best illustrated by sev- 
eral cases that have come under my observation : 

Ca.se I. — A man of 30 was under treatment for 
urethral hemorrhages and hematuria, apparently due to 
a congested, moderately tight, bulbomembranous stric- 
ture. There were symptoms of chronic vesical infection, 
but the cystoseope showed no changes in the bladder 
wall, nor did the prostatoscope reveal anything more 
than a congested prostatic urethra. The prostate was 
slightly enlarged and sensitive, but there was no ob- 
struction to urination. The urine was persistently tur- 
bid, and at times contained a small quantity of pus. 
Micturition was frequent and painful. Temperature 
and pulse were normal. The patient's general condition 
was excellent, although his habits were extremely bad, 
as he was addicted to drink and dissipation of various 
kinds, and was a subject difficult to control. The obstin- 
acy of the vesical symptoms, which persisted after a fair 
degree of dilation of the stricture had been attained, led 
me to suspect that something more serious than a simple 
cystitis from postgonorrheal infection existed. Careful 
microscopic examinations of the centrifuged urine made 
at varying intervals for a period of about six weeks, 
failed to show any findings other than those found in the 
ordinary cystitis coincidental with stricture following 
chronic gonorrhea. Inoculation of a guineapig with the 
urine was resorted to, with the result that in six weeks 
the animal developed distinct tuberculosis, both in the 
lymphatic glands and at the site of the inoculation. 



102 Amebioan Mbdicink] 



ECTOPIC GESTATION 



rjANCARY 20, 190« 

LVoL. XI, No. 3 



Tuberculin was afterward used in this case, combined 

with vesical instillations of iodoform, ether and albolene. 

All of the symptoms disappeared, and the patient has 

remained in perfect health, with the exception that the 

/ urine is a little turbid from time to time. 

Some time after the diagnosis was established by the 
guineapig test, bacilli were found in the urine, and 
although improvement was rapid and steady, the bacilli 
remained, and were found for a whole year after the 
patient was symptomatically well, with the exception of 
the cloudy urine. The patient has remained in excel- 
lent condition for the last two years, despite the fact 
that he has persisted in his old habita. No examinations 
of the urine have been made in two years, because of the 
indifference of the patient. 

Case II. — A young man of 28 was referred to me for 
operation for stone in the left kidney. The history of 
the case was very brief. The patient was in excellent 
health and had been all his life. For several years prior 
to consulting me he had had at intervals of a few months, 
attacks of renal polic, localized on the left side, attended 
by hematuria. On several occasions clot casts of the 
ureter were expelled. During the intervals between the 
attacks of hematuria the patient was perfectly well, save 
occasional lameness, tenderness, and slight pain in the 
vicinity of the left kidney, as he expressed it, "some of 
the time he knew that he had a kidney, and at other times 
he was unconscious of the fact." The temperature and 
pulse were normal. There was absolutely no perversion 
of general nutrition so far as I could determine. The 
appetite was good. The patient could do a fair amount 
of work as a clerk in a store. The finding of the rontgen 
ray was negative. The urine, while it contained a 
somewhat larger quantity of leukocytes than is usual, 
was otherwise absolutely normal, macroscopicly, micro- 
scopicly, and chemically. Repeated examinations of 
the urine showed bacilli to be absent. The guineapig 
test was made in this case, and up to the seventh week 
after the inoculation of the animal the result was appar- 
' ently negative. At the end of that time a nodule 
appeared at the point of inoculation, and the inguinal 
lymphatic glands showed a distinct enlargement. The 
microscope proved conclusively the process in the guinea- 
pig to be tuberculous. The patient in this case is still 
under observation and remains in about the same condi- 
tion as when first seen. He is at present making 
arrangements for a change of climate, which, consider- 
ing the incipiency of the tuberculous infection, may 
reasonably be expected to eflfect a cure. I shall certainly 
not consider operative interference until climatic influ- 
ences have had a fair chance. 

Case III. — A young woman of 20 had been troubled 
with backache and frequent micturition, with occasional 
hematuria for six months. General nutrition was im- 
paired, the patient having lost considerable weight, and 
the appetite being poor. There was, however, no eleva- 
tion of temperature. The urine contained pus and blood 
in small amounts, but was otherwise normal. There 
was not sufficent of the corpuscular ingredients to impair 
the clearness of the fluid. Cystoscopy showed no change 
of the mucous membrane of the bladder, and the urethra 
was apparently normal. Inoculation with tuberculin 
gave the characteristic reaction, and the guineapig test 
gave positive results. 

A diagnosis of incipient renal tuberculosis was made 
in this case. Treatment by tuberculin was not only not 
beneficial, but apparently detrimental. Change of 
climate was suggested, and the patient went to Arizona, 
whei-e she apparently recovered completely. Two years 
later she returned to her home in the East, and has since 
remained apparently well. 



The foregoing histories are illustrative of a class ot 
cases in which only too frequently the diagnosis is over- 
looked until very little hope of benefit can be offfered by 
the physician. It goes without 'saying that it is our 
duty to make a diagnosis as early as possible, and if, in 
order to make an accurate diagnosis, the means em- 
ployed in the foregoing cases are necessary, they should 
be undertaken at once. 



ECTOPIC GESTATION.' 



WILLIAM H. HANDLE, M.D., 

of Philadelphia. 

Obstetrician of the Jewish dospital of Philadelphia. 

Extrauterine pregnancy occurs much more frequently 
than is generally recognized. There are three varieties : 
Tubouterine, or interstitial ; tubal ; and tuboovarian. 
There have been a few cases of ovarian pregnancy re- 
ported. In regard to the etiology of ectopic gestation, 
it is common after long periods of sterility. This is 
probably owing to the fact that the sterility may have 
been due to chronic salpingitis, which, by a thickening 
of the tube and destruction of the cilia, prevents the 
normal passage of the ovum to the uterus and favors its 
implantation in the tube. Peritonitic adhesions and 
bands which obstruct the tube are also causes of ectopic 
gestation. Ectopic pregnancy has been found coinci- 
dentally with pus in the tube on the opposite side. 

Tubal pregnancy is not infrequent. In 3,500 general 
autopsies, Formad found 35 ectopic .pregnancies, or 1^. 
Abdominal surgery has revealed many cases of tubal 
gestation which otherwise would have remained unrec- 
ognized, and it has thereby added to our estimate of its 
frequency. Many persons are said to die each year in 
Philadelphia of "socalled heart disease" and other 
causes, when in reality the death is due to internal hem- 
orrhage from ectopic gestation. Repetition of tubal 
pregnancy has been noted on several occasions. Both 
tubes may be simultaneously pregnant. Twin preg- 
nancies have been reportetl, and Sanger and Krusen 
have reported cases of triple ectopic gestation. 

In regard to the pathology of this condition, the 
ovum, which ordinarily passes into the uterus after im- 
pregnation, attaches itself to the tubal wall and con- 
tinues to develop there. Naturally the conditions here 
are not so favorable as in normal gestation, and the tube 
soon becomes extravascular, thinner, and in most cases 
there is less and less resistance and a predisposition to 
rupture. 

The tube may rupture in one of four directions : (1) 
Into the abdominal cavity ; (2) into the folds of the 
broad ligament ; (3) into the space formed by adhesion 
between the tube and the ovary ; (4) into the uterus in 
cases of the tubouterine variety. Occasionally, tubal 
abortion occurs when the abdominal ostium of the tube 
is still open and the product of conception is discharged 
into the abdominal cavity. Rupture of the tube may 
occur at any period, and usually it takes place at the 
point of placental insertion. This rupture may be due 

1 Read before the Association of Ex-resident and Resident 
Physicians of the Jewish Hospital, October 2, 1905. 



J ANtTABY 20, 19061 

Vol.. XI. No. 8 J 



DIABETIC PURPURA 



(American Mbdicins 103 



i 



to direct tension on the tubal walls from the growing 
fetus ; from mechanical violence, from falling, lifting or 
jumping, and from coition. A digital examination may 
be the direct cause of the rupture. If the rupture occurs 
early in pregnancy, the hemorrhage may be less severe ; 
and if it is slight, we have the formation of a retro- 
uterine hematocele, which is generally encysted and 
gradually absorbed and often not recognized until some 
subsequent abdominal operation. 

The symptoms of tubal pregnancy resemble those of 
normal gestation. The usual signs, such as pigmenta- 
tion, fulness of the breasts, morning nausea, may be 
present or absent ; slight uterine hemorrhage may occur 
at irregular intervals. Colicky pains, probably due to 
uterine contractions, appear toward the end of the second 
month. The patient usually suffers more discomfort 
than in previous pregnancies. On a careful bimanual 
examination, the uterus is found enlarged with a mass 
on one side or the other, which may be mistaken for dis- 
ease of the appendages. The uterus is much smaller 
than is usually expected from the duration of the preg- 
nancy. According to Hofmeier, the pulsation of the 
artery on one side of the cervix, and not upon the other, 
is a valuable sign of extrauterine pregnancy. . 

The diagnosis of extrauterine pregnancy before rup- 
ture is rarely made, because the patient does not usually 
consult her physician. The diagnosis of this condition 
depends upon the following symptoms: 1. A history 
of early pregnancy. 2. A paroxysm of frightful pain, 
usually upon one side. 3. Sudden collapse, often with 
fainting. 4. Symptoms of internal hemorrhage, rapid, 
weak pulse, facial pallor, air hunger, and all the symp- 
toms of loss of blood. 5. Later, abdominal tenderness 
and distention. 

Vaginal examination will present the physical signs 
of effusion into the peritoneal cavity. In cases of doubt 
as to the diagnosis, a small vaginal incision may be 
made through the posterior vaginal vault, when the 
escape of free blood will verify the diagnosis. 

The symptoms of ruptured ectopic gestation have 
been closely simulated by the rupture of varicose veins 
in the broad ligament ; by the rupture of an ovarian 
cyst or the torsion of its pedicle ; or by a criminal abor- 
tion with perforation of the uterus in a case in which a 
felse history is purposely given ; or by pelvic tumors 
associated with intrauterine pregnancy. But as all 
these cases require abdominal treatment, a mistaken 
diagnosis is of little importance, because abdominal sec- 
tion gives an opportunity for proper treatment. A very 
frequent error which occurs in general practice is to 
mistake an extrauterine pregnancy for incomplete abor- 
tion. 

Prognosis. — Without surgical treatment about two- 
thirds of the patients die, the remaining third escape the 
Immediate danger of death. This statement is verified 
by Winkel in whose series of 265 cases, the patients in 
whom surgical treatment was not adopted 36.9^ recov- 
ered and 63.1 ^ died. Of those who do not die directly in 
consequence of tubal gestation, a large proportion remain 
chronic invalids as the result of various complications. 
In another series of 278 cases, in which there was no 
operation, collected by Schauta, Martin, and Orthmann, 



187 patients or a little oyer two-thirds died; while of 
636 patients operated upon, 507, or 80^ survived. 
Therefore so soon as the diagnosis is established with 
reasonable certainty, whether before rupture or after, 
abdominal section is the only treatment worthy of con- 
sideration. The use of electricity, and of injection into, 
or puncture of the sac, are discarded procedures ; and 
the removal of the sac and control of hemorrhage is the 
only plan justifiable. After rupture the patient's only 
salvation is immediate celiotomy, evacuation of the 
blood from the peritoneal cavity, the ligation of the 
bloodvessel supplying the sac, and its complete re- 
moval. 

This operation is often performed in a hurried man- 
ner, but time should be taken to secure absolute aseptic 
conditions of the field of operation, of the surgeon, assist- 
ants and instruments. As little anesthesia should be 
used as is possible and stimulation should be withheld 
until the bleeding-point is secured. When the abdom- 
inal incision is made, no attention should be paid to the 
enormous quantity of blood that gushes forth, but the 
operator should place his hand directly upon the rup- 
tured tube and clamp the bleeding parts. As soon as 
the bleeding-point is grasped, vigorous stimulation may 
be employed. The ruptured appendage should be re- 
moved after the broad ligament has been ligated en 
masse. The blood clots may be rapidly ladled out and 
the pelvic cavity quickly ilushed with a large quantity 
of sterile saline solution. A quantity of the fluid may 
be allowed to remain in the pelvic cavity. Drainage is 
rarely necessary, in fact is rather detrimental. 

For the first few hours after the operation active 
stimulation and treatment for the acute anemia is neces- 
sary. Hypodermoclysis, and intravenous injection of 
normal salt solution are invaluable. If the patient is 
not seen until after a hematocele has formed, a vaginal 
incision may be made with the evacuation of the clots 
which lie in large quantities in the pelvic cavity ; but 
the patient should be prepared for the abdominal opera- 
tion should it prove necessary because of the recurrence 
of hemorrhage. In some cases of intraligamentary 
pregnancy, it is possible to open the sac extraperitone- 
ally by an incision above Poupart's ligament, but as a 
safe all-round procedure which permits a nicety and pre- 
cision of work, the abdominal section is best. 



DIABETIC PURPURA.' 



C. HENRY LEPCOWITCH, M.D., 

of Philadelphia. 

Instructor of Pediatrics, JefTerson Medical College ; Assistant Pedtat- 
rlst to the Jeffersoa Hospital; Examining Physician to the 
Jewish Foster Home and Orphan Asylum, Phila- 
delphia. 

On April 1, 1903, Dr. Edwin E. Graham referred the 
patient with this interesting case to the Children's Out- 
patient Department of the Jefferson Hospital. 

Robert M., aged 3, was born with the aid of forceps, 
and was breast-fed for four months. Thereafter, mixed 
breast and bottle feeding was employed until the age of 
1 year. Dentition occurred at the age of six months. 

' Read at the meeting of the Philadelphia Pediatric Society, 
November 13, 1905. 



104 



Amkkican Mkdicink] 



DIABETIC PURPURA 



rjAWUABY 20, 1906 

LVOL. XI, No. 3 



The boy's father was healthy, but the mother com- 
plained of rheumatism and nervousness. The paternal 
grandfather died of tuberculosis, as did also an uncle on 
the mother's side. There are two other children living 
and healthy. No children have died, and there is no 
history of premature births. 

The boy has not suffered from summer diarrhea nor 
any other disease incidental to early childhood. Three 
months ago a bluish eruption appeared on the body and 
face. The eruption occurred in irregular patches, vary- 
ing in size from that of a silver quarter to a silver dollar, 
gradually fading from a dark blue or purplish color to 
greenish-yellow, and finally disappearing. Each lesion 
lasted from one to two weeks, and was followed by the 
appearance of new patches on other parts of the body. 

From beginning to end they resembled the lesions 
that result from contusions. 

There were also vesicles on the tongue, lips, and 
mucous surfaces of the cheeks, which bled readily. The 
appetite was poor, except for sweets ; the tongue was 
coated ; the bowels moved twice or three times a day, 
the stool being well formed, and dark brown in color. 
He urinated eight or nine times during the day and 
once during the night, occasionally soiling the clothing. 

Urine varied in color, contained some sediment, and 
sometimes discolored the underclothing, but at all times 
had a pleasant odor. 

On presentation, there was one purpuric patch on the 
angle of the right jaw, one over the right hip-joint, and 
one on the under surface of the scrotum and the peri- 
neum adjoining. 

He was well nourished and favored with a beautiful 
cherry complexion. He was nervous and practised mas- 
turbation. He never had fever. Heart, lungs, liver, 
and spleen were found normal on physical examination. 

No treatment was instituted until April 4, when a 
sample of urine was obtained and examined, with the 
following result : 

Urine turbid, light amber color, pleasant odor, reac- 
tion highly acid, specific gravity 1,036, sediment floccu- 
lent, no albumin, sugar present, 11 gr. to the ounce. 
Under a strict diet of skimmed milk, improvement in 
the glycosuria was noted. 

April 10: Urine clear, light amber color, pleasant 
odor, acid reaction, specific gravity 1,020, no sediment, 
no albumin, sugar present, 1 gr. to the ounce. Purpuric 
areas less distinct. Graham bread was added to the 
diet. 

April 18: Urine clear, light amber color, acid reac- 
tion, specific gravity 1,022, no sediment. Slight reaction 
to Boettger's test. Fermentation test shows only a trace 
of sugar. 

April 24 : For the past four days the child has suf- 
fered from an attack of follicular tonsillitis. Purpuric 
spots yellowish. A more liberal antidiabetic dietary 
allowed. Atropin sulfate, 0.2 mg. (^I^ gr.) at 1 p.m., 4 
p.m. and 7 p.m. for the enuresis. 

April 29 : Appetite ravenous, bowels regular, easily 
purged by fruit. Urinalysis shows a specific gravity of 
1,022, and a trace of sugar. Atropin sulfate, 0.2 mg. 
i^hv gi"-) foui" times a day. 

May 4: Appetite fair, bowels regular, gastric dis- 
comfort after eating meat ; still urinates frequently, 
although has better control at night. Urine clear amber, 
specific gravity 1,024, acid, no albumin, a trace of sugar. 

May 11 : Condition about the same. Slight evidences 
of purpura remain. Tincture of belladonna, six drops 
three times a day. 

May 23 : No signs of purpura present. Does not soil 
his bed or clothing so frequently, and urinates less often. 
Negative reaction to Fehling's and Boettger's tests, and 
no difference in the specific gravity after fermentation. 
Tincture of belladonna, 7 drops three times a day. 

May 30 : Urinates three or four times a day, has good 
control at night. Diet is judicious. Boy active and in 
good condition. 



June 4, 1904, one year later, the boy was pale and 
emaciated, the skin was dry and poorly nourished, but 
contained no marks of purpura. He presented the aspect 
of true diabetes. A hasty examination of the urine gave 
a positive reaction to Fehling's solution. The boy was 
then put in the care of the family physician for nine 
months and he is now comfortably healthy while on a 
judicious diet. 

Purpura is characterized by an extravasation of blood 
into the superficial or deeper tissues. According to 
Marfan,' the causes of secondary purpura may be classi- 
fied as : (1) Mechanical, traumatism or other causes alter- 
ing intravascular or extravascular pressure ; ,(2) nervous, 
in paralysis, sciatica, hysteria, deep emotion, or fright. 
Probably due, as S. Weir Mitchell asserts, to vasomotor 
relaxation or weakening of the walls of the bloodvessels ; 
(3) toxic, forming a part of some of the infectious dis- 
eases, as hemorrhagic smallpox, scarlet fever, and 
measles. A symptom in such diseases as enteric fever, 
diphtheria, lobar pneumonia and bronchopneumonia, 
angina, vaccinia, infectious endocarditis. In gastroin- 
testinal intoxications, severe jaundice, acute yellow 
atrophy of the liver. It may follow the ingestion of 
various vegetables and other articles of food. Purpura 
is found in cachetic diseases, tuberculosis, cancer, leuke- 
mia, pernicious anemia, pellagra, senile cachexia, dia- 
betes, Bright's disease. Barlow's disease, and in hered- 
itary syphilis. Purpura can be caused by various 
poisons, iodin, iodoform, potassium iodid, antipyrin, 
belladonna, arsenic, chloral, chloroform, alcohol, ergotin, 
phosphorus, quinin sulfate, salicylic acid, the balsams 
(copaiba, cubeb, santaloil, and turpentine), snake poison, 
and therapeutic serums. 

Indeed, most writers and textbooks give diabetes as 
one of the causes of secondary purpura, but no report of 
such a case could be found. This case is, therefore, put 
on record as showing the coexistence of these two inter- 
esting disorders of metabolism. It is also interesting 
because it proves that a true diabetes mellitus may fol- 
low an alimentary glycosuria. Furthermore, it justifies 
Morse's injunction as to the importance of a routine 
examination of the urine in infancy and childhood. 
This patient had been treated previously for enuresis. 
From a moderate experience, I have become quite firmly 
convinced that if Morse's teaching was universally fol- 
lowed, enuresis as a disease entity would vanish from 
the textbooks and would occupy no time in our clinics. 
Moreover, the value of an examination of the urine in 
infancy and childhood, when metabolic processes are 
comparatively simple, cannot be overestimated. 

I regret that the overcrowded condition of the old 
hospital prevented deeper pathologic investigation of 
the case, and that the report of one blood-examination 
made by Dr. John Funk was lost. 

In conclusion, I desire to express my gratitude to 
Dr. Graham for referring the patient, and also to my col- 
league, Dr. Wm. E. Pole, for the urinalyses. 

"The Archives of Physiologic Therapy." — The 

publishers announce that the printers' strike has delayed 
the December and January issues, and will also, in all 
probability, affect the February issue. 

1 Marfan : Traite des Maladies de I'Enfance, 1897, Vol. ii, p. 
154. 



JANDABY 20, 19061 
Vol.. XI, No. 3 J 



EXPERIMENTAL BIOLOGY AND MEDICINE 



fAMEBICAN MeDICINB 105 



SPECIAL ARTICLES 



SOCIETY FOR EXPERIMENTAL BIOLOGY AND 
MEDICINE. 

Proceedings Reported by the Secretary, 

WILLIAM J. GIES, Ph.D., 

of New York. 

The fourteenth meeting of the Society or Experi- 
mental Biology and Medicine was held in the Rockefel- 
ler Institute on Wednesday evening, December 20, 1905. 
The president, Edmund B. Wilson, was in the chair. 

Members Present. — Adler, Atkinson, Auer, Beebe, 
Brooks, Burton-Opitz, Calkins, Cramptod, Davenport,' 
Dunham, Emerson, Ewing, Field, Flexner, Gibson, 
Gies, Hatcher, Jackson,' Levene, Levin, Lusk, A. R. 
Mandel, Meltzer, Morgan, Noguchi, Oertel, Opie, 
Pearce,' Salant, Shaffer, Wadsworth, Wallace, Wilson, 
Wolf, Wood. 

MEMBER.S Elected. — W. E. Castle, H. H. Donald- 
son, David L. Edsall, Thomas Flournoy, R. B. Gibson, 
Walter Jones, A. S. Loevenhart, John A. Mandel, Fritz 
Schwyzer, Frank P. Underbill, Francis C. Wood. 

ABSTRACTS OF REPORTS OF ORIGINAL INVE.STIGATIONS.' 

" The action of eosin upon tetanKS-toxin and tetanus: " 
Simon Flexner and Hideyo Noguchi. 

1. Eosin and certain other anilin dyes have the power 
of destroying in vitro the hemolytic property of tetanus- 
toxin. 

2. Eosin, when used in sufficient quantity, destroys 
tetano-spasmin in vitro. 

3. Simultaneous injection of tetanus-toxin and eosin 
into rats delays or prevents the appearance of the symp- 
toms of tetanus. When the symptoms appear they 
progress more slowly than in control animals. 

4. Spores of tetanus-bacilli when introduced on 
threads into rats, together with immediate eosin injec- 
tions, do not produce tetanus. The treatment of ani- 
mals with eosin, after the first appearance of the tetanic 
symptoms following spore- infection, may prevent the 
further developments of the symptoms of tetanus. Eosin 
injections into the same locality as spore inoculations are 
the most effective, but injections into other parts of the 
body delay or modify the tetanic process. 

5. Rats are more resistant to tetanus than guinea- 
pigs, and hence are more easily protected by eosin from 
tetanus poison ; but in guinea-pigs the fatal issue can be 
delayed by eosin. 

" The action of eosin and erythrosin upon snake 
venom:'''' with demonstrations. Hideyo Noguchi. 
(Communicated by Simon Flexner.) 

1. The hemolytic principles of venom react differ- 
ently to eosin, depending upon their native labilities. 
The hemoly.sin of Crotalus venom suffers most ; that of 
Daboia next, while that of Cobra is the most resistant. 

2. The toxicity of different venoms is more or less 
diminished by eosin in the light. Cobra is least affected; 
Crotalus and Daboia venoms are most affected. Crotalus 

■ Nonresident. 

'The authors of the communications have written the ab- 
stracts. The secretary has made occasional abbreviations in 
some of them. 



venom loses its toxicity chiefly by destruction of hem- 
orrhagin, and Daboia by destruction of coagulin. 

3. Neurotoxin is little or not at all affected by eosin 
or erythrosin. 

4. There is a parallel between the susceptibility of 
the toxic principles of snake venom to fluorescent 
anilins and to other injurious influences. Hemorrhagin 
and coagulin are less stable at high temperatures than 
neurotoxin, and more easily destroyed by acids than 
neurotoxin and hematoxin. 

" On decomposition of purin bodies by animal tissues: " 
P. A. Levene and W. A. Beatty. 

The authors aimed in this work to study the products 
of decomposition of purin bodies in the tissues. Jones, 
Schittelhelm, and Levene have observed that amino- 
purins are transformed into oxypurins. It is well 
known that purin bodies undergo complete destruction 
in the course of tissue autolysis. 

The authors have studied the conditions most favor- 
able for the process of purin decomposition by animal 
tissues, and have endeavored to ascertain the general 
nature of the substances formed during the process. It 
was found that the presence of 0.5^ of sodium carbonate 
in mixtures of spleen pulp facilitated the decomposition 
of purin bodies to such an extent that even uric acid is 
broken up by that tissue. It was also noticed that the 
decomposition products were nonbasic in nature, for 
they were not precipitated by phosphotungstic acid. On 
decomposition of uric acid by tissue extracts, formation 
of ammonia could not be detected. 

" On the biologic relationship of nucleoproteid, amyloid , 
and mucoid:" P. A. Levene and John A. Mandel. , 

The authors endeavored to ascertain the nature of the 
carbohydrate groups in the protein molecule. It was 
found that by heating nucleoproteid on a water bath 
with a 5^ solution of sulfuric acid, a product could be 
obtained that had the properties of a polysaccharid or of 
a glucosid, and which contained in its molecule a small 
proportion of sulfuric acid (S = 0.5^). On treating 
nucleoproteids with alkali, substances were obtained 
containing a much greater proportion of sulfuric acid 
(S = 3.5fc; N = 8.8/c). The substances thus obtained 
were found to possess the properties of glucothionic 
acids containing small quantities of nucleic acid. 

Glucothionic acid has hitherto been recognized as a 
constituent of mucoid and amyloid. The results of this 
investigation place the three groups of substances in 
genetic relationship. 

'^Imperfection of Mendelian dominance in poultry 
hybrids : " with demonstrations of photographs and 
plumage-charts. C. B. Davenport. 

According to the Mendelian formula one of the pair 
of characters that are opposed in hybridization domi- 
nates over the other, occluding it ; the dominated, or 
recessive, character reappears in its pristine purity when 
the hybrids are interbred. 

A careful examination of the facts shows that in 
poultry hybrids the dominant character is frequently 
modified by the presence of the recessive and in the 
direction of the latter. For example, white plumage 
color may dominate over black, but the white hybrid 
shows some black feathers ; white dominates over buff 



106 IJHEBICAN MiCDICIKKJ 



EXPERIMENTAL BIOLOGY AND MEDICINE 



[January 20. l»06 
Vol. XI, No. 3 



plumage, but the hybrids have a buff cast. Pea comb is 
dominant over single, but the middle lobe of the hybrids 
is unusually high. Narrow nostril is dominant over the 
high nostril of the Polish fowl, but the hybrid nostril is 
exceptionally wide. "When the hybrids are interbred 
the recessive character reappears in about one-fourth of 
the hybrids, but often so modified as to be scarcely recog- 
nizable. The gorgeous bright red and golden but reces- 
sive plumage of the Japanese long-tailed fowl reappears 
in the second hybrid generation as a dull brick red, 
much mottled with black. The fact of the mutual con- 
tamination of characters in hybrids justifies the warnings 
■given by breeders as to loss of characters in hybridiza- 
tion, and the care that they exercise to maintain pure 
races. 

" The mechanism of conduction and coordination in the 
heart tcith special reference to the heart of Liniulus : " 
A. J. Caelsox (Presented by Russell Burtox-Opitz). 

I. The Rate of Conduction. — It is advocated, chiefly 
by Engelmann, that the rate of conduction of the 
impulse in the heart is too low (20 cm. to 30 cm. per sec. 
in the frog ; 2 m. to 4 m. per sec. in the dog) to take 
place in the nervous tissue. The slow conduction in the 
heart is thus construed as an argument in favor of the 
myogenic theory. This is based on the erroneous 
assumption that all nervous paths in the same animal 
conduct with the same, or practically the same, rapidity. 
The author has shown that this is not the case even for 
the motor nerves to the striated muscles. On the con- 
trary the rate of conduction in the nerve stands in direct 
relation to the rapidity of contraction of the muscle sup- 
plied by the nerve.' On this principle one would expect 
the rate of conduction in the intrinsic nervous plexuses of 
the alimentary tract and of the heart of vertebrates to be 
■as much slower than that in the motor nerves to the 
skeletal muscles as the contraction of the heart-muscle 
and the muscle of the digestive tract is slower than that 
•of the former. The rate of conduction in the intrinsic 
nerves of the vertebrate heart has not yet been deter- 
mined. In the heart of Limulus, this can be done by 
the ordinary graphic method. The author has shown that 
in the heart of Limulus the rhythm is neurogenic, not 
myogenic, and that the conduction and coordination take 
place in the nervous and not in the muscular tissue.'' 
The proofs of these conclusions are demonstrative. The 
■author has lately measured the rate of conduction in the 
■intrinsic heart nerves of this animal and has found it to 
be 40 cm. per second. The rate in the motor nerves to 
the limbs as found by the author is 325 cm. to 350 cm. 
per second. That is to say, the rate of conduction in the 
nervous plexus in the heart is from eight to ten times slower 
than in the peripheral motor nerves. 

II. Conduction in the Heart in the Stale of Water-Rigor. 
— The experiments of Fredericq, Waller and Reid, Bay- 
liss and Starling, Schliiter, Engelmann, Hofmann, and 
Bethe have shown that the heart walls may conduct 
without contracting or being able to contract. This can 
■be interpreted in two ways, viz. : (1) The conduction 
takes place in the nervous tissue, or (2) the conduction 

' Carlson : American Joarnal of Physiology, 1904, X, p. 401. 
'Carlson : American Journal of Physiology, 1904, xli, p. 67, 
1905, xii, p. 471. 



takes place in the muscular tissue, but the processes of 
conduction and contraction are so independent of one 
another that the muscle may conduct without contract- 
ing. The latter is the explanation usually adopted, 
based on the experiments of Biedermann and Engelmann 
on conduction in muscle in the state of water-rigor. 
Engelmann worked on the frog's heart. In the heart of 
Limulus the above two possible explanations may be 
put to experimental test. The author transsected the 
heart-muscle in the region of the second and the fourth 
heart-segments and dissected away a portion of the mus- 
cle about half a cm. in length, leaving the three portions 
of the heart connected alone by the nerve-plexus (the 
median nerve-cord, and the lateral nerves). The an- 
terior and the middle portions of the heart continue in 
rhythm in virtue of the impulses from the ganglion of 
the posterior portion, these impulses reaching the two 
anterior portions by means of the intact nerve-plexus. 
When this nervous plexus is severed in the fourth seg- 
ment, the region of the heart anterior to the sections 
ceases to beat. Hence, the anterior portion of the heart 
thus prepared beats in response to impulses that reach it \ 
through the nerve-plexus on the middle portion. Now, 
when this middle portion of the heart is placed in water, 
the muscle of this region absorbs water and ceases to beat 
or respond to artificial stimulation, while the anterior 
portion still beats in synchrony with the posterior por- 
tion of the heart. The nerves will also lose their con- 
ductivity if left in the water long enough. On replacing 
the water by plasma or sea-water the nerves are quickly 
restored. The muscle is restored very slowly and some- 
times not at all. The nerve-plexus in the Limulus heart 
is composed of nonmedullated nerves, just as is the intra- 
muscular nerve-plexus in the heart of vertebrates. Now, \ 
as the behavior of the Limulus heart and the heart of 
vertebrates in the state of water-rigor is the same, and, 
further, as the anatomic conditions (nerve-plexus and 
muscle-cells) are similar in both, it seems probable that 
the tissue concerned with the conduction in water-rigor 
is also the same in both. In the Limulus heart it has 
been demonstrated to be the nerve-plexus and not the 
muscle. In the vertebrate heart it has not been demon- 
strated to be the muscle. The recent experiments of 
Humblet, Hering, and Erlanger of transsecting on com- 
pressing the auriculoventricular muscle-bundle in the 
septum of the mammalian heart decide nothing relative 
to the myogenic or neurogenic nature of conduction and 
coordination, because it has been shown by Tawara that 
this muscle-bundle is surrounded and accompanied by a 
nerve-plexus similar to that in the auricles and the 
ventricles themselves. 

" Further obsenations on the effects of alcohol on the 
secretion of bile : " William Salaxt. 

In a previous communication ' on the effect of alcohol 
on the secretion of bile, it was stated that diminution in 
the rate of secretion of bile was observed after intra- 
venous injection of alcohol. No definite conclusions 
could be reached at that time, however, as to whether the 
diminished secretion was due to alcohol, for a steady 
decline in the flow of bile was very often noticed during 

I Proceedings of the Society for Experimental Biology and 
Medicine, IIKM, i, p. 4'?. 



JANUARY 20. IWKI 

Vol. XI, No. S J 



EXPERIMENTAL BIOLOGY AND MEDICINE 



[American Medicins 107 



the periods before the administration of alcohol. Recent 
observations in a series of similar experiments on dogs, 
in which the rate of secretion remained unchanged for 
several periods or differed slightly, showed marked 
diminution of the ilow of bile after intravenous injec- 
tion of alcohol. There was also a decrease in both the 
organic and inorganic constituents of the bile after 
intravenous injection of alcohol, but the relative 
amounts of solids were only slightly affected. The 
diminished excretion of solids, however, cannot be 
attributed to alcohol, for a wide range of variation pre- 
vails in the organic and inorganic constituents of the 
bile of untreated animals. 

The effects are entirely different when alcohol is 
introduced into the gastrointestinal canal. The methods 
employed in this relation were identical with those of 
the previous experiments. Anesthesia was induced by 
ether without the aid of morphin. In every case the 
neck of the gallbladder was securely ligated to prevent 
flow of bile from that direction. A cannula was then intro- 
duced into the common bile duct and the rate of secretion 
studied by comparing the quantities collected for periods 
of 15 minutes each. In those experiments in which 
secretion proved to be very scanty, the bile was collected 
for an hour and the quantity obtained during that period 
was compared with the amounts collected for equal 
lengths of time after alcohol injection. Various strength^ 
of alcohol were used : 25 ^ , 30 ^ , 50 ^ , 60 ^ , in quantities 
ranging from 1 cc. to 5 cc. per kilo, introduced 1 to 2\ 
hours after the introduction of the cannula into the 
common duct. 

With the exception of one experiment (XI in the 
accompanying table), the volume secreted immediately 
after the injection of alcohol into the stomach or into the 
intestines showed a marked increase as compared with 
the period immediately preceding the injection of alcohol. 
In 11 of the 12 experiments performed on different dogs, 
the percentage of increase, as shown in the accompany- 
ing table (II), ranged from 50^ to 365^. In a large 
proportion of the experiments, in which the dogs were 
apparently so exhausted that the secretion of bile reached 
a minimum, on introducing alcohol into the stomach or 
Intestine a striking improvement was noticed. In some 
experiments alcohol was injected both intravenously and 
into the intestines. The volume of bile secreted after 
the intravenous injection indicated a diminished rate of 
secretion, while in the same animal after the administra- 
tion of alcohol into the intestines the volume of bile 
secreted increased 140^ in one experiment and 80^ 
in another. The solid constituents were likewise mark- 
edly increa.sed. In one experiment there was an increase 
of 130^ in the total solids, 132;^ increase of organic 
matter, 115^ increase in the ash, the increase in volume 
in the same experiment being 140^ . In another experi- 
ment the total solids show an increase of 100^, organic 
matter 114^, ash '>9fc , the gain in volume being 125^. 
In two others the increase in volume secreted as well as 
in the amounts of solid constituents is HOfc in one; in 
the other, the percentage figures showing increa.ses in 
the secreted volume, total solids, organic matter, and 
ash were 160, 185, 195, 111.8, respectively, indicating 
that at least in a few cases some of the solid constituents 



may be increased in amount, both absolutely and even 
relatively, after introduction of alcohol. In this instance 
alcohol was introduced into the stomach. The excretion 
of inorganic constituents, while showing a wellmarked 
increase after the injection of alcohol into the gastroin- 
testinal canal, did not keep pace with the gain in pro- 
portion of organic matter. 

Further study is in progress. 



Table I. 



-Effects of Alcohol on the Elimination of 
Bile in 15-minute Periods. 



No. 


Before 

iDjecllon 

of alcohol. 


After Injection of alcohol 


Volume. 


Percentage 
increase. 


I 


cc. 
0.5 
0.5 

5(1 hr) 
0.15 
0.7 
0.4 
0.1 
0.2 
0.8 
0.8 
1.3 
0.25 


cc. 
1.2 
0.9 


140 


II 


80 


Ill 

IV 


1.0 (Ihr.) 
0.7 


100 


V 

VI 


1.8 1 160 
0.9 1 125 


VII 


0.4 ! SOfl 


VIII 


0.6 

05 

0.45 

1.8 

0.6 


100 


IX 


66 


X 


SO 


XI 




XII 


100 



Table II 


.-El 


FECTS OP 


Alco 


HOL 


ON THE Elimination of 




Solids in the Bile. 




Before injection. 


1 
After injection. 


Percentage increase. 


No. 




30 

•a 
_ o 






so 

2 

- o 






1 
olids. 

nic 
itier.' 

{anic 
alter. 











o 


r 


« t 


p 


3- 


ja |a 




> 


H 


< 


^ 


h 


< 


> 


H 




cc. 


me. 


mg. 


cc. 


mg. 


mg. ' 










I 


0.5 


S4.2 


4.6 


1.2 


7«.8 


9 9 


140 


130 


132 


116 


II 


0.6 
0.7 
0.4 


48.6 
74.0 
423 


1.2» 

9.3 

6.4 


0.9 
1.8 
0.9 


87.6 

211.1 

85.1 


11.8 ' 

19.7 

10.2 


80 
160 
125 


80 
1R5 
100 


195 
114 




Ill 


111.8 


IV 


59 




1 







•Calculated by difference from the total solids. The weights of 
organic matter are purposely omitted from the first two sections of the 
table. 

' Probably some analytic error accounts for this anomalous result. 

" Some effects on rabbits of intravenous injections of nico- 
tin:^' with demonstrations. I. Adlek and O. Hen.sel. 

A solution of 1 to 200 of the chemically pure nicotin 
furnished by Merck was used. Of this solution, i^ of a cc, 
equal to 1 J mg. of nicotin, was injected daily into the ear- 
vein of the rabbits. About ten seconds after the injection 
the animal is seized with a typical convulsion lasting 
from three to five minutes, after which it is apparently 
entirely well until the next injection, when the same thing 
recurs. This is repeated with great regularity and with- 
out any exception every day and no tolerance to the poi- 
,son seems to develop. In two animals it was attempted 
to gradually increase the daily dose to J cc. This, how- 
ever, proved too dangerous and was abandoned. All 
animals thereafter received the same daily dose of \ cc, 
which was never increased nor diminished. A number 
of animals died before they had received a sufficiently 
large number of injections to cause any definite lesion. 
Death ensued in some instances from some cause not at 
all referable to the nicotin poisoning, but in others from 
numerous small infarctions in the lungs, possibly caused 
by the intravenous injections. Cerebral hemorrhages, 
which are found so often in rabbits treated with adre- 
nalin injections, were never found in our animals. 

In animals which outlived a certain number of injec- 
tions, certain distinct and characteristic lesions were 



108 American Mkoicine] 



EXPERIMENTAL BIOLOGY AND MEDICINE 



C JANUARY 20, 1906 
Vol,. XI, No. 8 q 



found. It seems, however, that not all animals are 
equally susceptible. What has been observed in the 
numerous experiments with adrenalin seems t« be true 
also for nicotin. Now and then, how frequently we are 
not able as yet to say, rabbits are met with that will take 
their daily nicotin injection, responding with the typical 
convulsion, but after months of this treatment fail to 
show any of the characteristic lesions about to be de- 
scribed. These lesions seem to be identical in every 
respect with those found after intravenous injections of 
adrenalin. After 18 injections slight changes are appar- 
ent in the bulb and arch of the aorta. After 38 injections 
very marked and characteristic macroscopic and micro- 
scopic lesions can be recognized. Aneurysmatic dila- 
tions of the aorta are very distinctly visible. There may 
be either a single aneurysm, or, what is more frequent, 
several in various parts of the vessel. 

These dilations, as a rule, do not involve the entire 
circumference of the vessel, but only a limited portion 
of it, thus presenting the appearance of aneurysmatic 
pouches. On the interior surface of the aneurysmatic 
dilations and their immediate neighborhood, larger 
and smaller patches of calcification of varying shapes 
are apparent. Their margin is somewhat raised 
above the surface of the intima, their center some- 
what depressed. The more numerous the injections 
the more pronounced and extensive the alterations 
appear, but always of the same character. The authors 
have not yet concluded •their experiments and they have 
not yet been able to carry the number of injections 
beyond 50. The lesions here described have nothing in 
common with human arteriosclerosis. They are in 
every essential identical with what B. Fischer describes 
as the result of adrenalin and digalen injections. It can 
be demonstrated that the primary lesion takes place in 
the muscle cells of the media and first of all in those 
nearest to the intima. Here the nuclei become broken 
up, the chromatin is scattered, the entire cell becomes 
necrotic and is finally destroyed. This process gradually 
extends downward in the direction of the adventitia. 
As the muscle cells disappear, the elastic fibers, under 
pressure of the blood-current, are first stretched, then 
broken up. The entire wall of the vessel in this spot is 
thus attenuated and distended and finally calcified. 
There is distinct arterial necrosis. Thus far the authors 
have been able to find these lesions only in the aorta. 
The fact that they are found mainly in the aorta, that 
they occur in patches, that they begin with necrosis of 
the muscle cells and that thus far only adrenalin, digalen, 
and nicotin, all three vasoconstrictors, have been found 
to produce them, would suggest an affection of the vaso- 
vasorum as the underlying cause. This, however, is 
not yet proved. 

In all advanced cases the left heart has been found 
hypertrophied. Certain minute lesions have been found 
in the heart muscle. The kidneys have thus far only 
shown a moderate degree of hyperemia. An occasional 
trace of albumin appeared in the urine but never any 
sugar. In every case that has received a sufficient 
number of injections very definite changes are noted in 
the liver. The liver cells appear entirely normal, as do 
also the central vein and the interlobular vessels, but the 



interlobular bile ducts, even at a very early period, are 
found surrounded by a mantle of leukocytes which 
increases in volume after the injections are continued. 
The leukocytes not only surround the ducts but are 
found within the walls and even in the interior of the 
duct overlying the epithelium. This latter is always 
perfectly normal and the lumen, though perhaps here 
and there partially obstructed by leukocytes, is always 
sufficiently open to permit the free passage of bile. Bile 
is never found in the urine. In no case have the authors 
evfer found anything suggesting cirrhosis or degenera- 
tion of the liver cells. 

" Tumors of wild animals under guttural conditions: " 
Harlow Brooks. 

The author referred to the great importance of the 
etiology of neoplasms and the well-recognized fact that 
research along this line must now rest almost entirely on 
experimental studies of the lower animals. By this 
series of observations the author hoped to establish 
what may be called a "normal" rate of occurrence. 
This can be based only on observations of large numbers 
of animals which have been in captivity for only rela- 
tively short periods and which must be kept under far 
different conditions than is possible in the ordinary 
zoological park or in the laboratory animal house. 

The author's observations were made on a large num- 
ber of wild animals, most of which were captured direct 
from the wild, and which after capture and transporta- 
tion were placed under the most carefully studied 
natural conditions ever attempted in any large zoological 
collection. 

The occurrence rate of new growths in such a group of 
animals, comprising most of the known species of the 
reptiles, birds, and mammals should furnish a valuable 
contribution to the study of the etiology of tumors, espe- 
cially since the animals included in this collection were, 
for the most part, at least, pure and uncontaminated, 
except for such crossing as normally takes place in 
nature. The animals of the New York Zoological 
Society have been selected by experts for their purity of 
type and every one is submitted to a careful veterinary 
examination before becoming a member of the collection. 
Notwithstanding that this examination might have 
been expected in some cases to have excluded animals 
afflicted with tumors, the records show that none have 
been rejected for this defect. ' 

Of 2,645 living animals which have been under the 
charge of the author and his associates for the past five 
years, no case of true neoplasm has been found. Seven 
hundred and forty-four animals have died, and, as is the 
routine custom at the New York Zoological Park, have 
been autopsied, either by the resident pathologist or by the 
author. In this series of 744 consecutive cases but one 
case of tumor has been found. This case, significantly 
enough, was found in a white raccoon dog, an animal 
whose purity of species is decidedly in question and 
which has been classed by some zoologists as a ♦' sport " 
or albino. The animal has, however, been described by 
Hornaday as a new species, Nyctereutes Albus. The 
animal was secured in northern Japan, but was unrecog- 
nized by Japanese zoologists. The tumor in this case 
was found to be myxosarcoma of the ovary. Tumors of 



JANUARY 20, 19061 

Vol. XI, No. 3 J 



EXPERIMENTAL BIOLOGY AND MEDICINE 



lAMSRICAN MSDICINB 109 



parasitic origin, granulomas, tubercles, actinomycotic 
foci and the like are, on the other hand, relatively 
common. 

In addition to these data, the author also referred to 
various other animals, chiefly ruminants, taken in the 
wild, and of which none presented tumors. The latter 
observation was made by the author himself in the field 
and was in accord with statements of reliable guides and 
naturalists. 

The author felt that the number of cases cited was 
sufficiently large to permit him to conclude with a 
reasonable amount of certainty that true neoplasms are 
extremely rare in wild animals living under natural con- 
ditions. Abnormal conditions of life, such as close in- 
breeding, semidomesticity or contamination of species as 
seen in dogs, horses, cattle, and particularly in those 
animals usually employed for laboratory experiment, 
notably the white mouse, unquestionably increase the 
relative occurrence of new growths. 

" The cutaneous excretion of nitrogenous material:'''' 
F. G. Bexedict. (Presented by William J. Gies.) 

While the larger amount of the nitrogen excreted 
from the body is eliminated in the urine in the form of 
urea, uric acid, creatin, and allied compounds, nitrog- 
enous materials may also leave , the body in the feces 
and perspiration. There is, indeed, a possibility of the 
excretion of free nitrogen in the respiratory and intes- 
tinal gases ; for, unfortunately, although most physiol- 
ogists assume that no such excretion of nitrogen takes 
place, a fundamental demonstration of the correctness of 
this assumption is lacking. Usually, however, it is con- 
sidered that the total output of nitrogen is that in the 
urine and feces. It has long been known that nitrog- 
enous compounds are excreted through the skin, but it 
has commonly been accepted that the amount thus 
excreted is extremely small — in fact, too minute to take 
into consideration in ordinary metabolism experiments. 
An examination of the literature of the subject shows 
that widely varying results have been obtained. The 
most complete list of investigations into the subject of 
human perspiration that is acce.ssible to the writer is 
that of Hoelscher,' who, in studying human perspira- 
! tion under varying conditions, iixduced perspiration by 
hot-air baths and found as the average of 22 experiments 
in which 6,719 cc. of perspiration were collected that 
1,000 cc. of perspiration contained 7.1 gm. of solids, of 
which about 0.6 gm. was urea and the total nitrogen 
content 0.48 gm. 

Perhaps the largest recorded amount of nitrogen 
found in perspiration not induced by muscular work, 
was that obtained in experiments reported by Kijk- 
iinmn,^ in three experiments with Malay medical 
students in .lava. He obtained 0.222 gm. of nitrogen in 
a three-hour experiment, and in two 24-hour experi- 
ments 0.761 gm. and 1.362 gm. The subjects were 
engaged in light occupation, and the perspiration was 
induced by the tropic climate of Java. 

When perspiration is induced by severe muscular 



'Journal of the American Medical Association, pp. 1-16, 
lune 17, 189(1. 

■'Virchow's Arch. Path. Anat. u. Physiol., cxxxi, p. 170, 



exercise the elimination of nitrogenous material may be 
very large. 

In experiments in the author's laboratory with the 
respiration calorimeter ' the subjects of certain experi- 
ments devoted a considerable part of the day, i. e., eight 
hours, to work upon a stationary bicycle. The amount 
of nitrogen found in the clothes by extraction with dis- 
tilled water varied from 0.2 gm. to 0.66 gm. per day, the 
average of 88 days being 0.29 gm. 

In 1900 during a study of the food consumed and 
digested by four members of the Harvard University 
boat crew '' there was apparently a very great gain of 
nitrogen in the body. It was there pointed out that 
probably a not inconsiderable portion of the observed 
gain was to be accounted for by the fact that there might 
be a large loss of nitrogen in the profuse perspiration 
resulting from the very severe muscular exercise 
attendant upon training for a Varsity boat-race. 

In a recent study of metabolism with athletes, 
Lavonius' found in one case 0.14^, and in the other 
0.9^ nitrogen in the perspiration. Using the minimum 
figure and assuming from measurements of loss of body- 
weight that the weight of perspiration is about 1.8 kg., 
he calculates the loss of nitrogen to be 1.8 gm. per day in 
a circus athlete. 

It is thus evident that especially under conditions 
which result in profuse perspiration, such as tropic 
climate or excessive muscular exercise, a not inconsider- 
able excretion of nitrogenous material through the 
perspiration may take place, and further knowledge 
regarding the amount of nitrogenous material thus 
excreted is much needed. Furthermore, it is evident 
that data regarding the excretion of nitrogen under 
ordinary conditions where there is no sensible perspira- 
tion would be of considerable value. In connection 
with the series of metabolism experiments which are 
continually in progress in the /author's laboratory, 
opportunity was had to observe in a number of cases the 
excretion of nitrogenous material through the skin 
under conditions of both rest and severe muscular work. 
Method used in the author's experiments: Before 
the metabolism experiment began, the subject took a 
good scrubbing without using soap. This was followed 
by a shower-bath, and finally the whole body was care- 
fully sponged with clean cheese-cloth and distilled water. 
A union suit of cotton and cotton stockings were pre- 
viously thoroughly washed and extracted with distilled 
water, and after thoroughly drying the body they were 
put on. At the end of the experiment the union suit 
and socks were removed and the body carefully sponged 
with distilled water, all the wash water being carefully 
saved. The union suit and stockings were then extracted 
with distilled water several times (never less than four, 
and frequently eight). The water was made slightly 
acid to prevent any escape of ammonia during evapora- 
tion and the whole mass of wash water concentrated to 
a small bulk. It was then filtered Vnd only the clear 
filtrate evaporated, thus eliminating completely epithelial 

'United States Dept. Agr., Office Expt. Sta., Bull. l.Ui, p. 
118, 1!)0;!. 

•Atwater and Benedict: Boston Medical and Surgical 
.lournal, cxiiv, p. it{4, 1901. 

»Skan. Archiv., xvii, p. liKj, V.H>5. 



110 ahbsican Medicine) 



EXPERIMENTAL BIOLOGY AND MEDICINE 



rjANUARY 20, I90B 

LVOL. XI, No. 3 



scales, hair, fragments of clothing, or other dust. In 
consequence, none but water-soluble nitrogenous com- 
pounds are here considered. On evaporation, the liquid 
frequently was turbid and before final analysis it was 
filtered, the nitrogen in the filtrate in certain cases being 
determined separately from the nitrogen in the pre- 
cipitate. 

The samples were subjected to the usual Kjeldahl 
process for the determination of nitrogen. 

The experiments here reported consist of two kinds : 
(1) Those when the subjects were at rest ; and (2) those 
when the subjects were at severe muscular work. 

Typic rest experiment : Experiment with L. L. A. 
(December 16-22, 1904). 

The subject of this experiment, a man 24 years old 
and weighing without clothing 74 kg., remained in 
the respiration chamber seven days from December 
16-22, of which the first four days were without food 
and the last three days with food. During this period 
he was at rest, and, indeed, the routine of life was such 
as to call for much less muscular activity than that to 
which he was ordinarily accustomed. Practically all of 
the waking hours were devoted to sitting in a chair and 
reading or writing. The subject wore the union suit 
and stockings continuously from the beginning to the 
end of the experiment. After leaving the chamber, the 
water used in extracting the clothing and in sponging 
the body contained 0.722 gm. of nitrogen, or, since the 
experiment lasted seven days, 0.103 gm. per day. 

Conclusions regarding nitrogen excretion during rest : 
As a result of the data of this and similar experiments 
it has been found that even when the subject has no 
muscular exercise there is a measurable quantity of 
nitrogenous material excreted through the skin each 
day. While there is considerable variation in the actual 
quantity thus determined, the average is 0.068 gm. per 
day. 

The exact nature of the nitrogenous material thus 
excreted was not studied. That it is in large measure 
urea or ammonium compounds is highly probable, 
though the presence of soluble proteids is not at all 
impossible. Since in some cases, at least, the perspira- 
tion is alkaline and there would be a tendency to lose 
ammonia by gradual decomposition, these figures must 
be looked upon as representing the minimum rather 
than the maximum amounts, and the fact remains that 
the amount thus excreted per day is certainly worthy of 
consideration in metabolism experiments, especially 
where small quantities of nitrogen in the intake and 
output are involved. Zuntz ' has already noted this fact 
and estimates that the loss of nitrogen due to perspira- 
tion, wearing off of epidermis, etc., amounts to 0.46 gm. 
of nitrogen per day. What proportion of this loss is due 
to perspiration alone he does not state. 

Typic work experiment: Experiment with B. N. 
(January 23, 1905): 

During this experiment the subject, a professional 
bicycler, aged 28, and weighing without clothing 
62 kg., rode a bicycle ergometer in the respira- 
tion calorimeter for a period of four hours. The 
muscular exercise was very severe as was evidenced 

' Ber. d. deutsch. phariu. Gesellscb., xii, p. 363, 1902. 



by the fact that the subject left the chamber in a profuse 
perspiration, and the union suit and stockings were 
soaked with perspiration. The amount of muscular 
work performed may be seen from the fact that the total 
output of heat from this experiment was nearly 600 
calories per hour. The bath water gave in the filtrate 
0.063 gm. of nitrogen and in the precipitate 0.0037 gm. 
of nitrogen. The extract water from the clothing 
gave in the filtrate 0.785 gm. and in the precipitate 
0.018 gm. 

The total output of nitrogen, therefore, during this 
four-hour experiment was 0.87 gm. or 0.22 gm. per 
hour. 

Conclusions regarding nitrogen excretion during 
work : The increase in the amount of nitrogen-contain- 
ing material excreted through the skin when the subject 
is engaged in severe muscular labor is markedly notice- 
able ; for, while during rest experiments the amount of 
nitrogen thus excreted is about 0.068 gm. per day, hard 
muscular labor may result in an excretion equivalent to 
0.22 gm. of nitrogen in an hour. Furthermore, the 
results show with considerable regularity a nitrogenous 
excretion roughly proportional to the amount of work 
done; varying in these experiments from 0.22 gm. per 
hour in the experiment just described, when the most 
severe work was performed, to 0.13 gra. per hour in one 
of the other experiments in which the work done was 
less by about half. 

Of greatest significance is the important bearing of 
this channel for the excretion of nitrogenous material in 
experiments on the metabolism of proteid. Profuse 
perspiration, whether induced passively or by muscular 
work, results in a considerable excretion of nitrogenous 
material through the skin. While the work engaged in 
during these experiments was severe, certainly that of 
the second experiment described above was not extraor- 
dinarily so, and might well be equaled by many men 
engaged in occupations involving muscular work. A 
total excretion equivalent to one or more grams of nitro- 
gen per day is not at all inconsiderable, and hence in 
accurate metabolism experiments we must give recog- 
nition to the possibility of excretion through this hitherto 
almost unconsidered channel. Especially is this so in 
experiments where the total amounts of nitrogen in the 
ingesta and egesta are smaller than normal, since the 
percentage error is thereby proportionally increased. 

" The effects of intravenous injections of solutions of dex- 
trose upon the viscosity of the blood: " Russell, Burtox- 
Opitz. 

The experiments were performed upon dogs, in ac- 
cordance with the method devised by Hiirthle. When 
small quantities (5 cc.) of a concentrated solution of dex- 
trose were injected intravenously, the viscosity of the 
blood became slightly greater. By the administration 
of large quantities (50 cc. to 100 cc.) the viscosity was 
markedly decreased at first, but reassumed its normal 
value in the course of about one hour. 

By producing artificial glycosuria, the viscosity was 
decidedly increased. In the latter series of experiments 
the surface of the pancreas was painted with solution of 
adrenalin. The specific gravity of the blood pursued in 
all cases a harmonious course with the viscosity. 



JanFABY 20, 19061 
Vol. XI, No. 3 J 



DIGEST OF MEDICAL LITERATURE 



/American Medicine 111 



DIGEST OF MEDICAL LITERATURE 



GENERAL SURGERY. 

J. Chalmers Da Costa 
John H. Jopson Lawrence Hendee 

J. Coles Brick John W. Churchman 



THE BACTERIOLOGY OF THE URINE IN ITS RELA- 
TION TO SURGERY. 

A REVIEW AND DIGEST OP THE LITERATURE. 



JOHN W. CHURCHMAN, M.D. 
I The ultimate fate of the organisms which reach the 
iterior of the body cavities, more particularly of the 
organisms which reach the blood stream itself, has 
always been an interesting scientific problem ; but the 
inquiry as to whether that fate may be in part repre- 
sented by the glandular secretions, especially by the 
liver and kidney secretions, is one that has quite as 
direct a surgical as a purely bacteriologic bearing. Are 
we justified in regarding the urine and the bile as nor- 
mally perfectly sterile ; so that if, for example, an intra- 
peritoneal traumatic rupture of gallbladder or kidney be 
diagnosed, a subsequent peritonitis is not to be feared ? 
Or are we to regard these excretions as infectious and to 
regulate our peritoneal toilet and our general surgical 
attitude accordingly ? More than a "purely scientific " 
inquiry this surely is, for in this very question of per- 
itoneal toilet great carefulness in guarding the per- 
itoneum will be sure to follow a belief that the urine and 
bile are always infectious, just as careless technic is pretty 
sure to result from shaky bacteriologic convictions. 

Concerning the fate of circulating organisms in dis- 
ease, it has long been known that a certain proportion of 
them leave the body via the secretions. The contagious- 
ness of scarlatinal urine was a very early observation; 
long before the anthrax bacillus was discovered the 
ability of the urine to propagate the disease was well 
known (Schweizer) ; the typhoid bacillus was long ago 
found by Gaflfky in the renal vessels, and the occurrence 
of the tubercle bacillus in the kidney secretion is a matter 
of very common experience. The "cystitis 6 neph- 
ritide " of Bov.sing offers another clinical example. The 
more recent work, too, has amply supported the early 
findings in regard at least to typhoid fever, where the 
'luestion could be submitted to bacteriologic inquiry. 
Itichardson ("Upon the Presence of the Typhoid Bacillus 
in the Urine." Bo.st. Med. and Surg. Jour., clxviii, 6, 
I>. 152, 1903. "Recent Bact. Studies in Typhoid 
i -ver." Bost. Med. and Surg. Jour., cxxxviii, 7, p. 
I H, 1898), for example, in a large series of typhoid 
i'litients, i.solated the organism from the urine in 21.35^ 
"{ the cases, usually in pure culture and in enormous 
numbers.' Petruschky (" Uber Ma.ssen aus.scheidung 
von Typhus Bacillen, u. s. n." Centralbl. f. Bakteriol., 
xxiii, 14, 1898) and Gwynn ("The Presence of Typhoid 
I'.acilll in the Urine." Bulletin of the Johns Hopkins 
Hospital, X, 99, p. 109, June, 1899) reported similar flnd- 

' His opinion is that the orfranisms multiply rapidly In the 
ilHilder and do not actually come through the kidneys in such 



ings. L6pineand Lyonnet (" Sur I'infection typhique ex- 
p6rimentale chez le chien." Gaz. des H6p., 37, 1899) 
were able, after experimental intravenous inoculation 
with pure cultures of typhus, to isolate in a few hours 
the bacilli from the urine and bile; and Faulhaber 
(" iJber das Vorkommen von Bakterien in den Nieren bei 
akuten Infektions Krankheiten." Beitr. z. Pathol. Anat. 
u. allg. Path., X, 2 u. 3, p. 81, 1890) in a study of 53 
cases of infectious diseases of various sorts was able to 
cultivate the corresponding organism in 38. 

But it at once occurs to ask, whether this extrusion 
of organisms takes place through a perfectly healthy kid- 
ney ; and whether, if so, such a bacterial excretion is 
not constantly going in the healthy body, organisms 
absorbed in the intestinal canal and elsewhere being 
thus ushered out of the body. It may at once be said 
that ureteral bacilluria is, both as an experimental and a 
clinical observation, by no means always or necessarily 
accompanied by any signs or symptoms of nephritis that 
we can detect, and that if we are to speak from the clin- 
ical side alone, that is to say, without histologic exam- 
ination of the kidneys, we are justified in concluding 
that organisms often pass through perfectly normal 
kidneys. 

But, as a necessary preliminary inquiry, do organ- 
isms rea«h the kidney in, normal individuals? The 
answer at first given to this question was a decided 
no. Opitz (" Beitriige z. Frage d. Durchgiingigkeit von 
Darm u. Nieren." Zeitsehr. f. Hyg. u. Infekt., xxix, 
3, p. 505, 1898), in a fairly extensive research, supported 
the position previously taken by Neisser, and declared, 
as against results published by B6cos, that the unin- 
jured intestine was impenetrable by bacteria. Similar 
results were obtained by Marcus (" Uber die Resorption 
von Bakterien aus dem Darme." Zeitsehr. f. Heilkde., 
XX, 5 u. 6, p. 427, 1899), who was able to find no 
organisms in the urine 26 hours after ligating the in- 
testine and the urethra, and who stated that intestinal 
bacteria were retained by the lymph-glands in the in- 
testinal wall. Only after injuries to the intestine did he , 
find that organisms were able to pass through the wall. 
The bacteriologic investigation, too, of the normal 
organs made by Meissner, Hauser, and others strength- 
ened in an indirect way the idea of the impermeability 
of the intestinal wall to bacteria ; for the normal organs 
were found to be absolutely sterile, a finding that would 
not be expected if bacteria were constantly being ab- 
sorbed from the intestines and were circulating in the 
blood. 

On the other hand, certain observers claimed to have 
produced cystitis by ligating the intestine, and the not 
infrequently seen cystitides without known cause were, 
on this experimental basis, referred to an intestinal ab- 
sorption connected with constipation as their cause. 
Finkler and Prior (Centralbl. f. Allgem.-Gesundheits- 
Pflege-Ergilngungs-hefte, Bd. i. Heft. 5 u. 6), too, found 
the spirillum of cholera in the urinary bladder after 
injecting cultures of it into the duodenum. 

Moreover, Ford ("The Bacteriology of Healthy 
Organs." Transact. Asso. Amer. Physic, xv, p. 389), 
in a recent research has shown that the normal organs 
(liver, spleen, and kidneys, at least) are not sterile, but 



112 



Ahkrican Medicine] 



DIGEST OF MEDICAL LITERATURE 



rjAKUARY 20, 1906 

LVOL. XI, No. 3 



that organisms can be consistently grown from them ; 
and he thinks that the passage of organisms from the 
intestine into the mesenteric circulation bears some 
relation to digestive absorption. Boni (" Untersuchun- 
gen fiber den Keimgehalt d. normalen Lungen." 
Deutsch. Archiv. f. klin. Med., Ixix, 5 u. 6, p. 542, 1901) 
has found normal organisms in the lungs. It seems, 
then, probable that bacteria can and, from Ford's re- 
sults, do in normal cases reach the kidneys. Are they 
there excreted or withheld ? The early experiments on 
the permeability of the normal kidneys were made with 
coloring materials. Fonfick, Hoffmann, and Langer- 
hans, and von Riitimeyer — among others — showed that 
coloring matter injected into the circulation could be 
later found in the organs— at first in the vessels, later in 
the fixed cells of the connective tissue. Wyssokowitch 
(Zeitschr. f. Hyg. u. Infekt., Bd. i, p. 1), following 
this work up bacteriologically and endeavoring to 
find out what became of organisms injected into the 
circulation — their early disappearance from the blood- 
stream having been noted by Traube and Gscheidehn, 
by Fodor(*'Sitz ungserbicht der Mathematisch-Natur- 
wissen." Classe der ungarischen Akademie der Wissens- 
chaften von 18 Mai, 1885), and by Wyssokowitch him- 
self—was able, both by cultural and by histologic 
methods, to find the organisms in the organs themselves, 
where, by virtue of the results of his subsequent studies 
of the secretions (he found them sterile), he concluded 
that they went " zu Grunde." 

But is this conclusion justifiable? Or do the bacteria 
which we have traced up to the kidneys, and which we 
have found passing out of the circulation into the organs 
themselves, instead of dying out there, leave those 
organs by "excretion?" We know that in the case of 
many pathogenic organisms this does happen ; but it is 
then always possible to assume that we are dealing no 
longer with perfectly normal kidneys, and that the 
minute hypothetic renal lesions are responsible for the 
bacterial permeability. 

The opinions on this subject found in the literature 
are very variable. Kruse (Flugge's " INIikroorganis- 
men," Bd. i, p. 379) regards excretion through the 
secretory organs as unlikely, except when those organs 
are diseased, but_ thinks that these glands when healthy 
are not absolutely impermeable to bacteria. Fiitterer 
(" Wie bald gelangen Bakt., u. s. n." Berl. klin. Woch. 
xxxvi, 3, 1899) concludes, from his animal experiments, 
that organisms injected into the portal vein pass in 
enormous quantities through the normal kidney and 
liver. Biedl and Kraus (" Uber die Ausscheidung der 
Mikroorganismen durch die Niere." Archiv. f. exp. 
Path., Bd. xxxvii. Si. " Weitere Beitriige, u. s. n." 
Centralbl. f. innere Medizin, 1896,8.737. "Uber die 
Ausscheidung der Mikroorganismen durch drusige 
Organe." Zeitschr. f. Hyg. und Infekt., xxvi, S. 353) 
call the appearance of microorganisms in the glandular 
secretions "a true physiologic excretion." Opitz 
(" Beitriige z. Frage d. Durchgangigkeit von Darm u. 
Nieren." Zeitschr. f. Hyg. u. Infekt.. xxix, 3, p. 505, 
1898), after a careful experimental research, concludes 
that there is no such thing as a physiologic excretion of 
circulating organisms through the normal kidneys. 



HomtJn and Bonsdorff (" Die Wirkung der Strepto- 
kokken, u. s. n." Beitr. z. Path. Anat. u. allg. Path., 
XXV, 1, 1899), working with the streptococcus, find that 
pathologic alterations in the kidney are essential to the 
passage of organisms through it. von Klecki finds 
streptococcus, pyocyaneus and other organisms injected 
intravenously soon appearing in the urine, and the 
kidneys remaining normal. Pernice and Hcagliosi 
(" Uber die Ausscheidung der Bakt." Deutsch. med. 1 
Woch., xviii, 34, 1892) find pathogenic and nonpatho- 1 
genie organic organisms both passing through the kid- 
neys, but both producing local circulatory and degen- 
erative changes there. Casper (Deutsche med. Woch., 
xxxi, 30) believes that in advanced pulmonary tuber- 
culosis, tubercle bacilli get through the kidneys without 
causing any lesion there ; Schweizer (" Uber d. Durch- 
gehen von Bacillen durch die Nieren." Virchow's 
Archiv., ex ; ref. Baumgarten, 1887, S. 410) believes 
that the kidneys are bacteria-permeable, but that large 
numbers pass through only when the glomeruli are, in 
part, diseased ; Lister (Transact. Royal Soc, Edin. 
1875) finds the normal urine bacteria-Tree ; Damsch finds 
animal inoculations with urine from tuberculous patients, 
without urogenital lesions, negative; Wyssokowitch 
(Zeitschr. f. Hyg. u. Infekt., Bd. i, p. 1), after an ex- 
haustive and careful experimental research, decides 
emphatically against the possibility of bacterial excretion 
through uninjured kidneys. Noetzel (" Exp. Studie z. 
Frage d. Ausscheidung von Bakt. aus dem Korper." 
Wien. klin. Woch., xvi, 37, 1903) reaches the same 
conclusion. Cavazanni (" Uber die Absonderung der 
Bakterien durch die Nieren." Centralbl. f. Pathologic, 
1893, Bd. iv) finds Bacillus prodigiosus appearing in 
the urine after intravenous injection only when some 
kidney irritant (pyrogallol or cantharides) was simulta- 
neously introduced or when the renal artery was tied. 
Cohnheim (" Vorlesungen iiber allgemeine Pathologie ") 
thinks of the excretory capability of the normal kidneys 
as an admirable adaptation of nature for the protection 
of the body, and points to the excretion of bacilli in 
tuberculosis as a notable example of it. Thomas (Neu- 
bauer u. Vogel. Harnanalyse 8 Aufl., 2, Abth., S. 485) 
thinks the normal kidneys capable of bacterial excretion 
without themselves becoming diseased. 

There can be, however, no doubt that the majority of 
the most careful experimental work on this subject — as 
represented, for example, by the researches of Wyssoko- 
witch, Homf'n, and Opitz— speak strongly against the 
permeability of the kidneys for bacteria so long as they 
remain wholly without lesions — lesions which, as Opitz 
suggests, may be caused by the socalled "harmless" 
organisms. It is interesting to compare the findings in 
the case of the liver where bacteriologic studies of the 
bile have been made. Of course here, again, the bacte- 
rial content — at times the rich bacterial content— of the 
bile in certain diseased conditions is now well known ; 
in the case of typhoid fever, for example, it is a clinical 
commonplace. But is the bile in " normal " individuals 
sterile? L6tienne (" Recherches bact^ologiques sur la 
bile humaine." Arch, de Med. expcr., ill, G, p. 761, 
1891), in an examination of 42 corpses, found plates made 
from the gallbladder sterile in 18 cases; and he con- 



January 20, 1906T 
Vol. XI, No. 3 J 



DIGEST OF MEDICAL LITERATURE 



[Amkrican Hedicink 113 



eluded that the bile, while normally baeteria-free, was 
very readily infected in the case of infectious diseases. 
Ninni (" Contribuito clinico all'azione della bile normale 
8ul peritoneo." Rif. med., viii, 108, 1892) reported an 
interesting case of abdominal injury, with death from 
serofibrinous peritonitis, in which the section showed 
no cause for the condition beyond two wounds in the 
convex surface of the liver, through which bile had 
escaped into the cavity. Experimental research made 
subsequently by him led him to the conviction that the 
bile, if allowed to escape into the peritoneal cavity in 
large quantity, would set up there a serofibrinous peri- 
tonitis. Frankel and Krause (*'Bakteriologisches und 
Experimentelles fiber die Galle." Zeitschr. f. Hyg. und 
Infekt., xxxii, 1, p. 97, 1899), examining the gallblad- 
ders 1 to 40 hours after death found 108, out of 128 
examined, sterile, and decided thereupon against the 
excretion of organisms through the normal liver ; but 
the gall from 34 cases dead of tuberculosis with no 
intestinal or hepatic lesions, produced the disease when 
injected into guineapigs. The evidence is here again 
contradictory ; but there seems ground for suspecting, at 
least, that large quantities of bile, in a certain propor- 
tion of "normal" individuals, are infectious. In the 
case of the urine it is to be noted that no experiments 
have been made with really large quantities of the secre- 
tion and that the experimental evidence is for this 
reason not absolutely complete. Nor has sufficient 
attention been paid to the possible effect of digestion on 
bacterial absorption by a study of the urine immediately 
after meals. Still, allowing for these defects and gaps 
in the experimental evidence we are warranted in draw- 
ing the following conclusions : 

The normal kidneys — while possibly not absolutely 
impermeable to bacteria — play a very unimportant role 
in helping to rid the body of organisms. Only when 
they or their vessels have been injured do the bacteria 
escape in any quantity and then we are dealing with a 
pathologic and not a physiologic process. 

2. The urine from the normal kidneys, as studied at 
least in relatively small quantities and independently of 
digestion, is sterile. 

3. Organisms brought to the normal kidney meet 
their fate, for the greater part at least, by pa.ssing into 
the gland substance rather than through it into the urine. 

The normal urine then may, by the surgeon, be 
regarded as sterile. In large quantity, however, it may 
< ontain organisms. These have been found (Boni, Ford) 
in the normal organs ; and since all observers agree that 
slight kidney lesion is sufficient to make this organ 
permeable, it is quite possible that bacteria may leave 
the kidney via the urine more frequently than has been 
thought. The practical surgical conclusion from the 
work that has thus far been done is that even normal 
urine, while not to be feared in very small quantities, 
should always be treated with respect in peritoneal 
surgery. 



THE GENITOURINARY TRACT, 
llesults of Siibciitaiicons Administration of 
['hlorids after Neplirectouiy. — Brandenstein and 

liajes (Zeit. fur klin. Med., Bd. Ivii, p. 265) have based 
heir ex[}eriments on the theory that the edema of renal 



disease is due to a retention of chlorids. After the 
injection of moderately strong chlorid solutions into 
nephrectomized rabbits, they found that the percentage 
of sodium chlorid in the blood was barely increased, 
while the osmotic pressure and percentage of residual 
nitrogen were considerably raised. At the same time 
the refractive index of the blood-serum was reduced. 
For this reason the authors attribute the fall in the 
percentage of chlorids in the injected fluid to an increase 
of fluid, derived from the organism. An estimation of 
the chlorid content of the liver showed only a moderate 
increase, pointing to the conclusion that most of the 
retained chlorids accumulates in the bodily juices and 
not in the parenchymatous tissues. In most of the 
animals experimented upon, there occurred cutaneous 
edema, ascites and hydrothorax, which phenomena were 
more marked than in control animals injected with 
plain water. The authors explain the occurrence of 
edema in renal insufficiency primarily by the retention 
of certain organic substances, embraced in the residual 
nitrogen, together with a hydremic condition of the 
blood. These factors render the vessel walls more 
permeable, and fluid passes into the tissues. The 
abnormal accumulation of fluid in the blood and lymph 
vessels is explained primarily by the retention of 
chlorids, the excess of which holds back a corresponding 
amount of water. In the more advanced stages of renal 
insufficiency there may also be a direct disturbance of 
the function of water excretion in the kidneys, [b.k.] 

Examination Concerning' the Renal Function 
after Nephrectomy. — T. H. Schilling (Arch. f. 
Exper. Path. u. Pharmak., 1905, lii, 140) has operated 
upon the kidneys of 54 rabbits, performing 130 tests and 
urine determinations on them. He found that animals 
with one kidney void concentrated sodium-chlorid solu- 
tions given by mouth as quickly as normal animals, so 
long as the amount of water given them to drink is not 
cut down. If less than the usual amount is given, the 
saline solution is not voided so concentrated as in normal 
animals, and they require a longer time to excrete it. 
This is probably due to back absorption of water from 
the kidney. After compensatory hypertrophy has been 
completed, the kidney will have learned to do its 
increased amount of work, and to eliminate the sodium 
chlorid in the same manner as the two kidneys had 
done. If a great deal of spring water is given such 
animals, they require a longer time to secrete the urine 
as concentrated as before. The one kidney is not 
capable of removing large, intravenously introduced, 
isotonic sodium chlorid solutions so quickly as the two 
kidneys. Indigocarmin solutions are not excreted so 
concentrated as in normal animals ; and the animals 
with one kidney removed produced much less sugar, 
when phloridzin is injected, than do animals with two 
kidneys. This fact lends credibility to the view that in 
phloridzin diabetes the kidney is the point at which the 
sugar is formed. If, however, the hypertrophy con- 
tinues, the way to produce sugar is slowly learned by 
the organ. In cases of caffein diabetes there is no con- 
nection between the polyuria and the glycosuria. The 
diuresis arises as the result of the action of the caffein on 
the renal cells. The point of production for the sugar 
lies outside the kidney. In a number of cases, an 
increased amount of urine without a previous diminu- 
tion appears after nephrectomy. [E.ii.] 

Punctured Wounds of the Bladder. — E. Evans 
and H. A. Fowler (Annals of Surgery, August, 1905) 
state that wounds of the urinary bladder are extremely 
uncommon except when produced by a surgeon's instru- 
ment. They occur most frequently in military life. 
The writers report a case of puncture through the peri- 
neum entering the peritoneal cavity. They also sum- 
marize the literature of the subject. They divide 
wounds into tho.se presenting an external wound and 
cases of rupture. The bladder may be reached by pene- 
trating instruments through the suprapubic region, the 



114 Ahbricak MbdicinbJ 



INDEX OF LEADING ARTICLES 



[JANUAKY 20, 1906 
Vol. XI, No. 8 



obturator foramen, and the perineum. The diagnosis is 
rarely difficult. The escape of blood mixed with urine 
leaves no doubt. If there is prolapse of omentum, as in 
the case reported, or of bowel, there can be no doubt as 
to peritoneal involvement. If doubt exists, an explora- 
tory incision should not be delayed. Extravasation 
from a healthy bladder may not cause peritonitis for 
many hours, but in punctured wounds the danger of 
infection is increased many fold. In infected wounds 
the essential point is free drainage. Such a case will 
heal promptly with care of the wound and a retention 
catheter for a few days, or regular emptying of the blad- 
der every three hours. If the wound is small and the 
escape of urine insignificant, it should be opened up 
freely by incision and free drainage established. Intra- 
peritoneal wounds mean immediate laparotomy, closure 
of the wound by sutures, and removal of blood, urine, 
and foreign bodies from the peritoneal cavity. Statistics 
of intraperitoneal wounds are far from satisfactory, but 
are improving, as shown by the tables given, [h.m.] 



INDEX OF LEADING ARTICLES. 
Journal of the American Medical Association, 

Vol. xlvi, No. 2, January 13, 1906. 

" The Pathology of the Kidney: Some General Consid- 
erations." W. T. Councilman, Boston. 

" The Relation of the Kidneys to Eclampsia." Philip 
King Brown, San Francisco. See American Med- 
icine, Vol. X, No. 8, p. 803. 

"Cylindruria." Charle.s P. E.mebson, Baltimore. See 
American Medicine, Vol. x, No. 8, p. 303. 

" Canalization of the Sigmoid, the Lateral and a Portion 
of the Superior Longitudinal Sinuses for Mastoiditis 
of 21 Years' Standing, with Subsequent Reestablish- 
ment of a Temporomandibular Joint." Bavard 
Holmes, Chicago. 

" Hyperemesis Gravidarum." Charles Rosewater, 
Omaha, Neb. 

"The Operative Treatment of Fractures." James A. 
Kelly, Philadelphia. 

'^Further Studies on Streptococcus Infections." Gu.stav 
F. RuEi>iGER, Chicago. 

"Paroxysmal Tachycardia: Its Relation to Exophthal- 
mic Goiter." Carl C. Warden, Battle Creek, 
Mich. 

" The Present Status of Therapeutics." W. G. Moore, 
St. Louis. 

"Spirochete Obermeieri." F. G. Now and R. E. 
Knapp, Ann Arbor, Mich. 

" Indications for Strychnin and Nitroglycerin in Circula- 
tory Disorders." Orville Harry Brown, St. 
Louis. 

Medical Record, Vol. 69, No. 2, January 13, 1906. 

"Observations on Nephroptosis and Nephropexy." 

Arnold Stubmdorf, New York. 
" The Role of Saline Solution in the Treatment of Pneu- 
monia." J. Madison Taylor, Philadelphia. 
"An Inquiry Into the Scientific Principles Which 

Underlie the Milk Feeding of Infants." Thomas 

8. SouTiiwoRTH, New York. 
"Obstruction of the Pylorus." Robert Hurtin 

Halsey, New York. 
"Clinical Aspect of Rheumatic Endocarditis." James 

D. Morgan, Washington, D. C. 
"A Nonoperative Method of Treating Prostatitis." 

William Benham Snow, New York. 
" A New Method of Treatment of Acne." Eli Mosch- 

cowiTZ, New York. 

Boston Medical and Surgical Journal, Vol. cliv. 
No. 2, January 11, 1906. 

" A Report of Three Cases of Perforated Gastric Ulcer : 
Gastroenterostomy." Daniel Fiske Jones, Boston. 



" Analysisof the 120 Casesof Malaria Occurring at Camp 
Gregg, Philippine Islands." Weston P. Cham- 
berlain, U. S. A. 

"Shoes and Feet." Robert Soutter, Boston. 

" Dazzling Health Statistics." Thomas J. Mays, Phila- 
delphia. 

New York Medical Journal, Vol. Ixxxiil, No. 2, 
January 13, 1906. 

" Friedreich's Ataxia, with a Report of Thirteen Cases." 

Wharton Sinkler, Philadelphia. 
" Reflex Neuroses, with Special Reference to the Appen- 
dix Vermiformis." Egbert H. Gbandin, New 

York. 
"Uterine Inertia and Its Management."' George L. 

Brodhead, New York. 
"The Pathologic Physiology of Typhoid Fever." 

Joseph H. Barach, Pittsburg. 
"A Simple Instrument Useful in Rontgen Raying a 

Stricture of the Esophagus." Swithin Chandler, 

Philadelphia. 
" A Contribution to the Causation of Enchondroma of 

the Upper Portion of the Femur." C. O. Thikn- 

haus, Milwaukee, Wis. 
" A Quarter Removed After 219 Days in the Esophagus 

of a Child." J. J. Rectenwald, Pittsburg. 
"The Physiology of Recreation." G. W. McCaskey, 

Ft. Wayne, Ind. See American Medicine, Vol. x 

No. 23, p. 934. 
"Gonorrheal Rheumatism." Martin W. Ware, New 

York. 

The Lancet, Vol. clxx. No. 4297, January 6, 1906. 

The Sanatorium and the Treatment of Pulmonary 
Tuberculosis. The Question Considered in 
Its Therapeutic and Economic Aspects. " The 

Therapeutic Value of the Treatment of Consump- 
tion on Sanatorium Lines." Richard Douglas 
Powell. 

" The Sanatorium Treatment of Pulmonary Tubercu- 
losis." William H. Broadbent. 

" On the Objects and Limitations of Sanatoriums for 
Consumptives." C. Theodore Williams. 

" The Therapeutic Value of Sanatorium Treatment in 
Pulmonary Tuberculosis." J. Kingston Fowler. 

"The Sanatorium Treatment of Pulmonary Tubercu- 
losis." Frank J. Wethered. 

"The Economic Value of Sanatoriums." Arthur 
Latham. 

" Sanatoriums for Consumptives." F. R. Walters. 



' : 



" A Medley of Surgery." E. E. Goldmann. 

" A Case of Ochronosis." Frank M. Pope. 

"A Note on the Relationship of Alkaptonuria to Och- 
ronosis." A. E. Garrod. 

" A Case of Operation on the Vestibule for the Relief of 
Vertigo." Richard Lake. 

British Medical Journal, No. 2349, January 6, 1906. 

MThe Medical Aspects of Carcinoma of the Breast." 
William Osler. 

" Three Cases of Arterial Disease." T. Clifford All- 
butt. 

"The Action and Uses of Digitalis in Cardiac Failure." 
J. Mitchell Bruce. 

"A Clinical Study of Lepra Ophthalmica, with a 
Description of Cases Examined at the Leper Hos- 
pital in Laugarnes, Iceland, in 1901 and 1904." 
Karl Grossmann. 

"An Investigation of the Mechanism of Condylotomy 
for the Cure of Genu Valgum (Reeves' Operation)." 
Walter C. Stevenson. 

"The Influence of Acid on Guinea Worm Larvas En- 
cysted in Cyclops." Robert T. Leiper. 



American Medicine 



David Riesmas 
Allek G. Eli.is 
M. B. Hartzkll 
Norman B. Gwys 
Helen Mtjrphy 



GEORGE M. GOULU, Editor 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Rugh 
Bernard Kohn 
John W. Churchman 



G. C. C. HOWARD, Managing Editor 



COLLABORATORS 

A. O. J. Kelly 
WiLMER Krusen 
John Knott 
Lawrence Hendee 
A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. Rhein 
J. Coles Brick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pylb 
D. Braden Kylk 
Eugene Lindauer 
Alfred Gordon 



Published Weekly at 1321 Walnut Street Philadelphia bv the American-Medicine Publishino Company 



Vol. XI, No. 4. 



JANUARY 27, 1906. 



).00 Yearly. 



Smallpox a Luxury. — Reiteration of tlie value of 
vaccination and tiie consequent necessity for laws com- 
pelling its acceptance by those who would not of their 
own free will seek its protection, would be unpardon- 
able were it not for the numbers of the opposition. 
From the medical point of view there seems logically 
only one side to the question, but there are physicians as 
well as laymen who insist upon the uselessness and even 
Janger of the process. In a very plain statement re- 
..■ently issued to the taxpayers of Pennsylvania, Commis- 
fnoner of Health Dixon presents solely the financial 
ispect of neglected vaccination, with the hope of thereby 
impressing those to whom statements regarding sick- 
lees and death do not appeal. At the lowest esti- 
! oate it costs the State $350 for each person outside of 
ities quarantined to prevent the spread of smallpox. 
'his means that during 1903 more than $2,000,000 of 
tate money was thus expended, or, as well put by Dr. 
)ix()n, was wasted simply to gratify a whim of those 
iio oppose vaccination. If such people do not appre- 
:ite this waste of money, surely those who are protected 
s' vaccination are entitled to protest against the re- 
Hirces of the State being " consumed in this way in 
■ilcr to permit a few obstinate fanatics to indulge their 
t fancy of being allowed to have smallpox if they so 
'Sire." A remedy mentioned by Dr. Dixon, namely, 
Heting the cost of controling smallpox by a tax upon 
ose who refuse vaccination, would doubtless prove a 
oiig argument to such recalcitrants. The experience 
' Williamsport in expending $284 for each of 18 cases of 
lallpox and at the same time protecting some thousands 
< persons by vaccination at a cost of 29 cents each, 
mid appeal to persons whose gray matter can be 
iHed only by excitation of their pocketbooks. Ver- 
iy, smallpox is a " luxury and not a necessity ! " 

Tlie age at which drunkenness is established 

investigated by Dr. Chas. L. Dana,' and his con- 
' New York Medical Record, July 27, 1901. 



elusions, being based upon some thousands of cases, are 
not only of great scientific value, but have a practical 
application as well. Briefly, it might be said that in- 
ebriety usually begins before 20 years of age, and if a 
man has not indulged to excess before he is 25, he is not 
likely to do so later. There are so few who begin ex- 
cessive drinking between 30 and 40 years of age, that one 
who has reached the age of 30 without excesses is almost 
surely safe. Dana stated that no cases arise after 40 
years of age. There is a popular idea, no doubt, that 
numerous cases do arise after 40, but it is not at all un- 
likely that investigation into their early histories will 
bring to light a long series of occasional overindulgences 
with some symptoms dating back to childhood. Dana 
evidently refers to real inebriety in youth, and not to 
the lapses which so many young men wrongly assume 
to be a part of their education, nor does he assert that all 
youthful inebriates are incurable, but merely that old 
cases began at an early age. Wild oats must be reaped 
in sorrow and pain, but* they do not necessarily choke 
the whole crop of good seed. These statistics are of 
such profound significance that it is quite remarkable 
they have elicited so little comment and have not been 
made the basis of practical measures for the prevention 
of drunkenness. 

The cau.se of the early incidence of inebriety 

is not known, and probably cannot be discovered until 
there has been more investigation of the pathogeny of 
this disease, and there now seems to be no reasonable 
doubt that there is a pathologic basis for the craving. 
Of course, it is also generally . believed that there is a 
habit generated by the pathologic changes wrought by 
the alcohol itself, and that in the immature years these 
effects are more easily produced than later. Dana 
seemed to believe that it was a matter of habit and 
environment, though it had a neuropathic basis. It was 
one of the accidents befalling the nervously unstable, 
who are not sufficiently protected until age could work 



116 Ahbbican HedicinbI 



EDITORIAL COMMENT 



CJaNUABV 27, llxi. 
Vol. XI, No. 4 



greater stability. The average healthy man might, and 
perhaps does, outgrow his youthful indiscretions, but the 
defectives cannot. There might be some cases congen- 
itally so neurasthenic as to'be unable to stand the ordi- 
nary stresses of life and who would drift into drunkenness 
or vagabondage no matter what guards surrounded their 
childhood. It is hard to believe they are numerous, 
though the wish may be father to the thought. The 
neurasthenic cases constitute but 20 fo and it is easier to 
believe that in most of the.se the weakened nervous con- 
dition is acquired. Ten percent are periodicals, and here 
a real defect of development can be assumed, the causes 
having been active either prenatally or in the early 
years of life, with bad heredity probably an additional 
factor. These few cases are the only ones in which we 
can afford to be pessimistic as to prevention in youth 
and early manhood. The 70 fc who are mere besotted 
drunks seem to be results of the habit of indulgence acci- 
dentally acquired in a bad environment, the original 
nervous instability having been most probably the nor- 
mal condition of youth exaggerated, to be sure, though 
not to a pathologic degree. There is some evidence of 
more or less neuropathic taint in relatives of these unfor- 
tunates, but how often is not known. 

Paying boys to abstain from alcohol is a dis- 
tinctly modern movement and though it has a firm 
scientific basis for a trial, it was no doubt suggested to 
many a father as a means of protecting his sons from 
dangers which nearly wrecked his own life. Every 
little while we learn of some boy who has been promised 
a certain sum upon his twenty-first or twenty-fifth birth- 
day or even yearly — the sole condition being abstinence 
from alcohol, tobacco, or both. The average boy will 
work for such a prize as a matter of course, and it will 
tide him over the period in which alcohol does the most 
harm. If it is really true that abstinence until 25 in- 
sures a life of sobriety, by all means let the scheme be 
extended to more boys until it becomes fashionable. 
Boys are sticklers for custom and will shun drink as soon 
as it becomes bad form. Happily it is a method which 
cannot possibly do harm even if it is not based upon a 
true hypothesis — and its possibilities of good seem so 
large that it would be criminal not to try it. Should 
the early incidence of alcoholism really mean that it is 
due to a pathologic nervous instability — and there is no 
reason to believe it to be so caused except in the minor- 
ity of cases — then the boy is apt to be abnormal anyway, 
if not alcoholically then in some other habit. Yet it is 
reasonable to believe that many of these cases, after a 
few years of right living with good food, might become 
sufficiently stable to be in no further danger, and then 
they could indulge moderately or not, as they please. 



Perhaps, also, much of the disease is due to poor nour- 
ishment in infancy and childhood, so that there are 
other things to be done beside inducing abstinence in 
youth. There are many causes to be discovered and 
eliminated so that pledges and bribes are only adjuvants 
after all. We are drifting in the right direction any- 
how. Edward Eggleston' says: "It was estimated 
early in the eighteenth century that about one building 
in every ten in Philadelphia was used in some way for 
the sale of rum," and in Massachusetts, Governor 
Belcher was afraid that the colony would " be deluged 
with spirituous liquors." The outlook is not so bad that 
we need worry. We cannot permit nature to evolve 
national sobriety by her old trick of killing off' all the 
drunkards, the method explained by Dr. G. A. Held, in 
his book on alcoholism. It is too expensive in valuable 
lives — prevention is the new method in this day and 
generation. 

A legal defliiition of " practising medicine," 

as the term is used in the New York statutes, has been 
handed down in a dissenting opinion by Justice Joseph 
M. Deuel, of the Court of Special Sessions, in the case 
of an osteopath who had been prosecuted by the County 
Medical Society, and fined for practising medicine with- 
out a license. It is the same Justice Deuel who is suing 
the editor of Collier's Weekly for libel, as a result of 
an editorial statement criticising the Justice for connec- 
tion with Totvn Topics. The Justice remarks that the 
practice of medicine consists of three things — diagnosis, 
discovery of the cause, and the cure by drugs, and that 
if a doctor does not prescribe drugs he is not prac- 
tising medicine. This must be wormwood and gall 
to the therapeutic nihilists, and it should stimulate our 
pharmacologists and therapeutists to renewed activi^ 
in their efforts to restore their special science to its at 
one time preeminence. In the meantime, the surgeon 
who reduces a dislocation and the physician who cures a 
tuberculous patient with cold air and good food, are not 
in the practice of medicine at all. It is difficult to com- 
ment temperately upon such a blow at the medical pro- 
fession ; indeed, it is not possible to follow out the 
mental processes which result in such a conclusion. It 
is to be hoped that there are no other legal minds so 
constituted. He also stated that the statutes aimed to 
suppress "the ignorant and indiscriminate administra- 
tion of drugs and lotions," though it must be a curious 
man who will administer a lotion. It is said that 
already the osteopaths are to use this remarkable deei 
sion to fight for recognition and for a license to practise! 
medicine without medicines, and knowing nothing of 
medicine. They are to make much of the statement 



> Century, May, April, 1885. 






JANUARY 27, 1906-] 

Vol. XI, No. 4 J 



EDITORIAL COMMENT 



(AUEBtCAN MeDICIKI 



117 



that this particular defendant did no harm, even if he 
did no good. They will get small comfort, for it is quite 
doubtful if there are any other justices who have such 
views on medical topics. 

C: A case of superfetation has been reported from 
Albany, N. Y., in the lay press. It is asserted that a 
j'oung woman of 20 gave birth to a full-term child on 
August 29, and 116 days later to another, both now liv- 
ing. Dr. Greo. T. Moston, of 611 Central Avenue, is 
reported to have attended the woman in the second con- 
finement, but there was no physician in attendance at 
the first, nor can the nurse be found. The family are 
apparently astonished and this astonishment is the only 
evidence of the truth of the phenomenon. Of course, 
superfetation is possible during the first three months 
after the first conception, but after this time the uterus 

j is hermetically closed and impregnation is impossible. 

} Nevertheless, the alleged cases do not stand investiga- 

I tion, and it is generally believed that there are no 
authentic instances with a normal uterus. It is said 
that one twin might be born and the other delayed 
owing to lack of development, but this explanation is 
merely a guess, and is useless until authentic cases are 
found. In the rare event of a double uterus the phe- 
nomenon is possible, and in 1855 Fordyce Barker re- 
ported such a case, in which he attended the woman, a 
mature male being born July 10, and a full-term female 
on September 22. The Albany case should be investi- 
gated, for it is certainly unique if it can be authenticated. 
The French obstetricians are rather inclined to believe 
such cases possible, while the English and Germans are 
quite sceptical. The Albany profession can clear up the 
matter, which at present cannot be accepted as authentic 
until it is shown that the first child was really born of 
the same mother as the second. 

The child's environment is receiving more and 
more attention every year, on account of the growing 
conviction that heredity has been much overworked in 
accounting for juvenile depravity. Long ago there was 
a reaction against Lombroso's extreme views as to inher- 
ent and inherited criminality. He no doubt did find 
that many criminals were quite abnormal, physically 
and mentally, but it is now thought that these defects 
are not always inherited, but due to bad surroundings 
or poisoning in early infancy, or even in intrauterine life 
— alcoholism, and the like. In addition, it is found that 
many criminals are not more abnormal in body or 
brain than the noncriminal class, but were taught to be 
evil in childhood. According to our consular reports. Prof. 
Lino Ferriani finds than 80 fo of Italian child criminals 
[ are really normal children, who were taught wicked- 



ness in a bad environment, about two'-fifths having 
criminal parents. Upon this theory our sociologic 
workers have been removing child oifenders from the 
environments which injured them. From time to time 
very gratifying results have been recorded, and the last 
report of E. Fellows Jenkins, chief probation officer of 
the children's court of New York, is exceedingly good. 
In three years 3,377 youthful convicted offenders have 
been released on parole in the custody of parents and 
guardians and 83.2 fo have recovered normal moral tone. 
It is shown that there are regular schools in New York 
where boys and girls are trained to crime, the instruc- 
tors selecting the brightest boys for the work and using 
dummy figures to teach pocket picking, as in the days 
of Dickens' Fagin. It isn't heredity, then, at all, but 
environment which makes so much of our criminality. 
The human ovum, like every other organism, reacts to 
its environing forces, and will grow correctly if it is in 
a correct environment. It tends to the average or 
normal if permitted, and is never abnormal unless forced 
to it by exceptional forces ; that is, it tends to resemble 
its ancestral type and not necessarily its parents. These 
new reports as to criminality are certainly bound to have 
wide iniiuence upon our future work in the slums. The 
effort now is in the direction of preventing the forma- 
tion of criminals, and not the cure of the criminal who 
is incurable. The child must be grown as carefully as a 
farmer grows his plants. 

" That Last Waif" is the title of one of the works 
of Horace Fletcher and is based upon an experience in 
Chicago in which he was brought face to face with the 
system whereby little tots were turned into the streets 
to be drilled in crime. The awful environments of these 
babies fully explained to him the reasons for their abnor- 
mal growth and he has joined in the modern crusade to 
stop the production of criminals. It well repays one to 
read this little book, for though it is somewhat too 
optimistic as to the expected results, it is splendid testi- 
mony as to the value of the environment. It is appar- 
ently forgotten that many a child has been too greatly 
damaged in intrauterine life to become normal. No 
amount of attention after birth will suffice. Luckily 
these prenatally doomed victims of parental vice, dis- 
ease, or accident are in the small minority. The point 
of this whole matter is this, how long will society permit 
men to bring babies into the world to be thrust into the 
streets as soon as they can toddle to become parasites on 
the social organism. The parents of the street waifs are 
the real criminals and it is time to investigate if they 
cannot be compelled by law to pay for the proper rearing 
of their children or suifer confinement themselves as 
public enemies. We are running into socialism too fast 



118 



Ahbbican MkdicineJ 



EDITORIAL COMMENT 



rjANCJABY 27, 1906 

LVOL. XI, No. 4 



in this respect, for it will be a long time before the State 
can naturally assume the duties of a family and raise 
children. It requires too much individual care for each 
one, and the parent must give it or remain sterile. 

The indeterminate sentence has been discussed 
by Samuel J. Barrows, secretary of the Prison Associa- 
tion of New York City, in a report to the State Confer- 
ence of Charities, and it is gratifying to know that this 
most natural system is gaining such recognition. Not 
only is it in accord with modern views on heredity, but 
it is found to be an essential, beneficent, and economic 
feature of our judicial system. The basis of this work is 
the fact that juvenile offenders are not subjects for pun- 
ishment, but for removal from the evil surroundings 
which have injured them. To treat them as criminals 
is to make them criminals, for it is known by sad experi- 
ence that confinement of a boy among hardened men is 
to doom him to a life of crime. The juvenile courts, 
which are now being established everywhere, are de- 
signed to wipe out this blot upon our civilization— the 
child is simply put on probation. Older boys and those 
who have relapsed must be given a sentence which 
means confinement until cured. A board, in which 
medical men are represented, should decide in each case 
whether or not the convict can be released on parole, 
and, of course, he is not to be released until some means 
can be found whereby he can earn his living in proper 
surroundings. There is now a proposition to apply the 
system to every offender and stop the farce of confining 
incorrigibles for short periods and then turning them 
loose to prey upon society until caught again. It is even 
demanded that inebriates shall be similarly dealt with. 
The whole plan is so reasonable and so in accord with 
modern ideas that it is desirable to have it universally 
adopted. It merely means that every offender against 
society is to be confined until it is moderately certain he 
will not ofitend again, and that if he is incurable it will 
be far better for him and for society to confine him for 
life. No convict should be confined for a fixed time, nor 
should he be released unconditionally. He should be 
reconflned at any time he relapses. Unfortunately, it 
will require the voluntary cooperation of generous and 
humane people, and this aid may not be forthcoming. 

The problem of the unemployed is as old as man- 
kind. " Why stand ye here all the day idle ? " was said 
in the parable of the employer to the idle laborers in the 
market-place 20 centuries ago, and the same types of 
men nowadays have annual parades in London. The 
cry for help is thus two-sided — one-half the world seems 
to be seeking work but cannot get it, and the other half 
is seeking workers but cannot find them. Thousands 



are practically homeless, while there are thousands of 
good homes waiting for them if they will only work. 
We have 150,000 tramps in the United States— even 
France is said to have 20,000. Careful investigations in 
Belgium some years ago revealed the fact that all the 
vagabonds were profoundly neurasthenic, utterly unable 
to furnish the nerve force to work. Whether this con- 
dition was due to congenital defect or the poor feeding 
of childhood or exhaustion of diseases is not known, but 
it is known that efforts to place these men at work gen- 
erally fail for this reason, they cannot work, they are 
unemployable parasites upon society. Charles Booth 
says that the " modern system of industry will not work 
without some unemployed margin, some reserve of 
labor," and "for long periods of time large stagnant 
pools of adult effective labor power must lie rotting in 
the bodies of their owners, unable to become productive 5 
of any form of wealth, because they cannot get access to ; 
the material of production," while "facing them in 
equal idleness are unemployed or underemployed masses 
of land and capital, mills, mines, etc., which, taken in 
conjunction with this labor power, are theoretically com- 
petent to produce wealth for the satisfaction of human 
wants." If this means anything it means that a certain 
percentage of mankind is always incompetent for one 
reason or another and that there are always places to be 
filled and but few to fill them, though many men are / 
idle. " Many are called but few are chosen." 

Civilization is unjustly blamed for poverty, for 

investigations into ancient conditions show them to be 
far worse than present ones. Even as late as the time 
of Henry VIII poverty was so extreme and extensive 
with its accompanying diseases that the average duration 
of life was only half what it is now. Modern laborers 
live in a condition which would then have been con- 
sidered extreme luxury. The only difference between 
old and new times is the fact that formerly there was 
no help extended to those in temporary need of it, while 
now it is practically impossible to starve to death except 
by the slow process of improper food. In savage life 
periodic periods of starvation are the rule ; indeed in 
isolated higher communities also. Civilization is a com- 
pact organization for preserving all the units and to 
bind the whole more firmly together. It is not exactly 
charity which does this, but modern mutual aid, through 
every conceivable form of operation, which even goes to 
the point of preserving burdensome units, which can 
never render material assistance. 

Public pauperism is really parasitism and it 

seems to be a modern disease, due to the very ease with 
which assistance can be obtained. Man, like every 



January 27, 1906"1 
Vol. XI, No. 4 J 



EEVIEWS 



[AMERICAN MEDICrSK 119 



other organism, takes the path of least resistance. Once 
relieved of the necessity for the struggle for existence, he 
ceases to struggle and his power of work atrophies. He 
then lives at theexpense of the organism to which he 
is attached. There is a large class of men who derive 
good incomes from railroad accidents which they skill- 
fully bring on. It is even reported that men have vol- 
untarily suffered serious injuries even to the point of 
losing legs, and all for the sake of the pension. Since 
biblical times, and long before, paupers existed in 
every civilization, but it is only within a century that 
they have become a dreadful public burden ; they were 
formerly more apt to be hangers-on or retainers of the 
well-to-do. The appalling increase of public paupers in 
I^^ngland is now being duplicated in America, and it is a 
real disease of society, a disease due to an abuse of 
natural laws. It follows the rule of every disease due to 
atypic and abnormal cell growth of any kind. From 
being benign it can become malignant and can injure the 
organism (society) or even destroy it. It is a very 
natural result of our necessity to save every human life 
and prolong it to its greatest length. It therefore be- 
hooves physicians, who are more vitally interested in 
the matter than any other class of life-savers, to look 
into the cause of the disease and the remedies. It is to 
the interest of every worker to reduce the number he 
must support in idleness, so the problem comes home to 
every citizen. It is even found that a large pension is 
apt to curse a man instead of blessing him, for he ceases 
the struggle for a living and is content with mere food 
and lodging. Nothing is more pitiable than the state of 
men who are pensioned too soon. It is a sociologic 
necessity to render aid only when it is needed and com- 
pel men to keep up the struggle for existence. The 
present trend of thought is in the direction of relieving 
society of its burdens and shifting them to the shoulders 
of the individual families or relatives. In addition, 
there is a growing protest against the indiscriminate and 
maudlin charity which is thought to be responsible for 
the dreadful increase of pauperism. 



Memorial to the Late Dr. Joseph Leidy. — A cir- 
cular has been issued by a number of public-spirited 

i citizens asking for contributions toward a fund to erect 
a statue of Dr. Joseph Leidy on the City Hall Plaza, 
Philadelphia, in recognition of his memorable work in 
the field of natural science. It is pointed out in the cir- 
cular that nothing has been done in Philadelphia to per- 
petuate the memory of the famous physician, whose 
life's work was intimately associated with the advanced 

> place which this city holds and has held in the scientific 

world, although such recognition is not lacking else- 

. where. Dr. Leidy was universally recognized as the 

^r most distinguished figure which American science pro- 

, I duced in the last century. This city was the scene of his 
labors for an uninterrupted period from 1840 to 1890. 
He was born here in 1823 and died in 1891. 



BOOK REVIEWS 



Postoperative Treatment. — By Nathan Clark 
MoR.'^E, A.M., M.D. P. Blakiston's Son & Co., 
Philadelphia, 1905. 

The author gives an epitome of the different methods 
in use by various surgeons in their treatment of post- 
operative conditions. Throughout, this is supplemented 
by the author's own experience. He has treated the 
subject on broad lines, taking up, first, the general prin- 
ciples of care in such conditions, then particularized, 
treating of the conditions following surgical procedures 
in the various regions of the body. The author not only 
discusses the care of the wound itself, but also the gen- 
eral care of the patient. The work is well illustrated and 
should be of value, especially to those students starting 
in practice without hospital advantages. 

A Textbook of Physiological Chemistry. — By John 
H. Long, M.S., Sc.D. Philadelphia : P. Blakis- 
ton's Son & Co., 1905. 

Written for students of medicine, this book is a clear 
and concise exposition of the principles of physiologic 
chemistry, and places this complex subject in a very 
clear light, being purposely made elementary. Examples 
and exercises are introduced in smaller type, thus fur- 
nishing the basis for a laboratory course. Under the 
consideration of the blood are given some of the chemic 
aspectsof the problems of immunity. The book con- 
tains 410 pages of text and 32 illustrations. We regard 
it as a very good student's textbook. 

A Compend of Medical Chemistry, Inorganic and 
Organic, including Urinary Analysis. — By Henry 
Leffmann, A.m., M.D. Fifth edition, revised. 
Philadelphia: P. Blakiston's Son & Co., 1905. 

It is not»of(en that a book of the apparent character 
of Leffmann's " Compend of Medical Chemistry " is so 
thorough, so clear, and so authoritative as the volume 
under review. Regarding compends in general, we may 
quote from the author's preface: "It may be said of 
compends that they are books that most professors and 
reviewers condemn and that nearly all students use. 
The truth is that in the present systems in professional 
schools students are obliged to meet two distinct require- 
ments. They must study for the knowledge necessary 
for the practice of the profession, and they must study 
to pass examinations. The latter are, in so many cases, 
arbitrary in scope and affected by the personal equation 
of the examiner that the student cannot be blamed for 
resorting to a concise presentation of the more important 
facts of the science, supplementing this by notes of the 
narrower and more strictly personal items of the teach- 
ing." Especially to be commended is the fact that the 
little book holds in view the practical relation of chem- 
istry to medicine, and selects its facts and illustrations 
accordingly. We can see uses for it not only by students, 
but by older physicians who have not been able to keep 
pace with modern chemistry as it has developed. 

Materia Medica and Pharmacy. — By Reynold 
WF.Bii Wilcox, M.A., M.D., LL.D.' Sixth edi- 
tion, based on the fifth edition of White and Wil- 
cox's Materia Medica and Therapeutics. P. 
Blakiston's Son & Co., Philadelphia, 1905. 

This book has been revised to conform with the new 
United States Pharmacopeia, but it retains all the good 
features which have heretofore won it favor with stu- 
dents of pharmacy as well as students of medicine. Its 
therapeutic recommendations are based upon experience, 
and, on the whole, are to be depended upon. If it errs 
at ail, it is on the side of brevity. 



120 Amekican Mkdicinkj 



AMERICAN NEWS AND NOTES 



[l 



ANUABY 27, 1906 

Vol. XI, No. 4 



AMERICAN NEWS AND NOTES 



GKNERAL. 

Mexican Medical Congress — The first Medical Con- 
gress ever held in Mexico City, convened last weelc. 
Much attention was given to sanitary science. President 
Diaz received the delegates to the Congress at the Castle 
of Chapultepec. 

A Move for Cuban Sanitation. — President Palnaa 
has urged upon the Parliamentary Committee of the 
Moderate, or administration, party the necessity for 
granting a special appropriation by Congress for sanitary 
^purposes. The members of the committee promised to 
take up the matter in the House of Kepresentatives this 
month. 

Youthful Marriages in Manitoba.— A marriage 
license recently reached the Department of Agriculture 
at Winnipeg from a Galician settlement, which gave the 
ages of both contracting parties as only 12 years, and 
as a result the legislature passed a bill amending the 
marriage laws so that no one can marry under 12, and 
up to the age of 18 the consent of the parents must be 
received. 

"Malted Milk ; " How to Obtain It — A medical 
exchange gravely gives the following news item : ' ' Goats 
to Furnish Malted Milk. — It is reported that the Depart- 
ment of Agriculture is to experiment in typhoid fever 
with the milk of goats recently imported from Malta. 
The goats were subjected to a rigorous quarantine and 
have been carefully inspected to determine their freedom 
from disease.'^ 

Urge a Health Portfolio.— The Legislative Council 
of the American Medical Association has adopted resolu- 
tions recommending a Department of Public Health be 
established with a representative in the Cabinet; the 
repeal of the canteen law ; government control of the 
wandering tuberculous ; the regulation of the practice of 
medicine at Hot Springs, Ark. ; bespeaking the influ- 
ence of the entire medical profession in securing uniform 
State laws regulating the manufacture and sale of 
patented and proprietary medicines, and asking the 
government to exclude from the mails and interstate 
commerce all remedies the constituents of which are kept 
secret. 

Six-day Quarantine in the Canal Zone. — The 

canal zone medical authorities, considering that the 
zone is free from infectious diseases, has imposed a six- 
day quarantine and requires an inspection of all ves- 
sels from Bocas del Toro and Colombian and Venezue- 
lan ports. Immunes and black Jamaicans are exempt 
from quarantine. The quarantine hospital is opened 
and the steamship agents at Bocas del Toro and at Co- 
lombian and Venezuelan ports have been instructed to 
collect fifty cents from each deck passenger and $2 each 
from saloon passengers, for hospital fees. The steam- 
ship companies will be held responsible for the settle- 
ment of these dues. 

Isthmus Health Report.— The December report of 
Dr. W. C. Gorgas, the chief sanitary oflicer of the Pan- 
ama canal zone, says the sanitary conditions of the 
Isthmus are excellent. The last case of yellow fever in 
the city of Panama occurred November 11. The sick 
rate among the white employes is very low, but is high 
among the negroes, who are suffering from an epidemic 
of pneumonia. The yearly deathrate among the white 
employes is 8 per 1,000 and among the negroes 42. Dr. 
Gorgas gives as the reason for the difference in the rates 
the fact that the whites observe the sanitary regulations 
better than the negroes. The sanitary chief defends his 
methods from the attacks recently made on them. 



E.\8TERN STATES. 

For Protection of Food. — In order that the Massa- 
chusetts State Board of Health may have further power 
in protecting articles of food from gathering dirt and 
germs of disease by exposure to street dust, by contact 
with insects and diseased persons, the Woman's Health 
Club of Boston has prepared a bill which will soon be 
presented to the Legislature. 

Erysipelas Germs in Money.— A case of erysipelas 
due, it is believed, to the sufferer coming in contact with 
money containing germs of the disease, is being treated 
at the hospital for contagious diseases at Lynn. The 
patient is a cashier in one of the large provision stores of i 
that city. Her removal to the hospital was not at all 
compulsory, but was done simply as a matter of precau- 
tion. 

Liquor Sales by Pharmacists. — A bill is before the 
Massachusetts House for legislation relative to the sale 
of intoxicating liquors by registered pharmacists in no- 
license cities and towns. It provides that they may sell 
them upon the prescription of a registered physician 
practising therein, that no such prescription shall be re- 
filled, that such prescriptions shall be retained and kept 
on file, together with the name of the person for whom 
they are filled, and that the police authorities and police 
officers of the town shall at all times have access to such 
prescriptions and names. A penalty of not less than $50 
nor more than $100 is prescribed. 

Race Suicide. — Representative W. L. V. Newton, 
of South Boston, has had drawn up and will present in 
the Massachusetts Legislature a resolution to provide for 
the appointment by the Governor of a commission to 
consider the matter of race suicide. The resolution asks 
that a commission of three persons be appointed by the 
Governor to consider what steps can be taken to counter- 
act the tendency known as race suicide, and especially to 
prevent discrimination by landlords against tenants with 
children. The commission shall consider what, if any, 
legislation in the premises is expedient or possible, and 
what means, if any, might properly be taken by the 
commission to arouse public opinion in respect to the^ 
aforesaid evils. 

NEW YORK AND VICINITY. 

Harvey Society. — The sixth lecture in the course 
will be given at the New York Academy of Medicine on 
January 27, at 8.30 p.m., by Professor Llewellys F. 
Barker, of Johns Hopkins University. Subject, " The 
Neurons." t^ 

To Abolish Death Penalty. — Assemblyman Eagle- 
ton, of New York, has introduced a bill to abolish capital 
punishment and substitute therefor imprisonment for 
life. It is considered to have a direct bearing upon the 
renewed agitation over the case of Albert T. Patrick. ^ 

Drug Men Oppose Heyburn Bill. — At the annual 
meeting of the Drug Trade Section of the. New York 
Board of Trade and Transportation, the Committee on 
Legislation was instructed to oppose the passage in Con- 
gress of the Heyburn Pure Food bill, or of any meas- 
ure containing similar provisions. 

The Gibl)S Memorial Prize of the New York 
Academy of Medicine.— In addition to and as a partial 
correction of the statements published in the early De- 
cember issues (1905) of all the large medical weeklies of 
the United States concerning the Gibbs memorial prize 
essays on the " Etiology, Pathology, and Treat- 
ment of the Diseases of the Kidneys," the trustees 
of the New York Academy of Medicine announce: 
1. The prize amounts to $2,000 this time. 2. The 
prize essays may be handed in October 1 (not Jan- 
uary 1), 1907, or before that date. 3. The prize 
committee does not expect the " etiology, pathol- 



January 27. 19061 
Vol. XI, No. 4 J 



FOREIGN NEWS AND NOTES 



(Amekicak Mkdicinb 121 



ogy, and treatment" of the diseases of the kidneys to 
be discussed with equal completeness, but will be satis- 
lied with the thorough scientific consideration of part of 
the problem, provided an essay offered in competition 
contains new facts or discoveries or points of view of 
sufficient merit. 

Pupils May Avoid Vaccination.— Assemblyman 
Patton, of Erie, has introduced a bill into the New York 
House providing that no child shall be debarred from 
attending school because it has not been vaccinated, if 
the parents or guardians shall make a statement that 
they are of the belief that vaccination would be preju- 
dicial to the health of the child. 

Diphtheria Closes Stateii Island School. — The 

Board of Health of Stapleton, L. I., ordered the public 
school at Linoleumville closed, because of several ca.ses of 
diphtheria in the vicinity. Inspector Sprague sent all 
the pupils home, and with a corps of men fumigated the 
building. A teacher in the school was removed to the 
hospital, suffering from diphtheria. An Italian boy in 
the school first caught the disease and then the teacher 
was taken ill. Another case has been reported. 

Im PHIIjADBIjPHIA, PENNSYLVANIA, ETC. 

^ Women's Hospital's Big- Year. — Reports read at 
the annual meeting of contributors showed that 24,091 
' cases of all kinds were treated during 1905 at the Women's 
I Hospital, Philadelphia. The hospital has been endowed 
I with several beds and received in cash over $51,000 dur- 
ing the year. 

Medical Cluh's Officers. — The following officers 

were elected at the annual meeting of the Medical Club 

of Philadelphia. President, Dr. Roland G. Curtin ; 

vice-presidents, Brs. W. Sinkler, Henry Beates and M. 

B. Hartzel ; secretary. Dr. J. G. Taylor ; treasurer. Dr. 

j Louis Adler, .Ir.; governor, Dr. G. G. Davis; executive 

I committee, Drs. H. H. Whitcomb, of Norristown ; 

I Emery Marvel, of Atlantic City ; Wilmer Krusen, E. 

E. Montgomery and Ernest Laplace. 

Measles Becomes Epidemic in Philadelphia. — 

Typhoid fever cases last week showed a decrease in num- 
>, ber of 27, as compared with previous week," and^he health 
authorities are hopeful that the disease is on the wane. 
On the other hand, measles again showed a large in- 
crease, and the reports returned cases from every ward 
in the city with the exception of one. Director Coplin 
says that some at least of the apparent increase is due 
probably to the fact that the new health law requires 
measles among the transmissible diseases physicians 
are required to register. 

SOUTHERN STATES. 

Smallpox Subsiding'. — The smallpox scare in Spott- 
sylvania county, Va., is subsiding. Quite a number of 
I)er8ons are in quarantine, but no new cases have devel- 
oped. Many people have been vaccinated and the phy- 
Bicians are still busy in that line. 

WESTERN STATES. 

California State Institutions. — The State Board of 
Charities reports the following number of inmates in the 
various institutions of the State: State Hospital at 
Stockton, 1,099; at Napa, 1,491; at Agnews, 1,063; at 
Mendocino, 067 ; and in southern California, 833. 

News from the West Coast.— Southern California 
Medical College is to have a new $25,000 library, given 
by Dr. .Jarvis Barlow. — St. Luke's Hospital, San Fran- 
cisco, will have a 150,000 maternity wing. Work will 
Start at once on the building. — Articles of incorporation 
have been filled in Los Angeles for a hospital for the 
relief of tuberculous Hebrews. — Mrs. MillicentOlmstead, 
of San Gabriel, Cal., has deeded $200,000 worth of prop- 
'■rty for the purpose of establishing a free hospital. 



FOREIGN NEWS AND NOTES 



GENERAL.. 

Health Beg-iilations of Brazil The Health Officer 

of Brazil expresses dissatisfaction with the results of his 
inspection of quarantine methods and facilities and of 
the way in which the health regulations of the republic 
are observed in the northern ports. He reports that 
the general health of northern ports is good, but that 
there is a good deal of smallpox and yellow fever in 
Manoas, and that • the latter malady is prevalent in 
Belem, the port and capital of Para. 

London Proves Healthy City. — The annual report 
of the medical officer for the county of London shows 
that London is a healthy place to live in. Its marriage 
and birthrates, however, are extremely low. Indeed, in 
1904 the birthrate was only 27.9 for every 1,000 persons, 
this being the lowest recorded rate since the institution 
of civil registration. The marriage rate further declined 
from 17.5 to 17 for each 1,000 persons living. The 
deathrate for the year was 16.1 to the 1,000, which is 
much below the average of the previous 10 years. 



OBITUARIES. 

Swan Moses Burnett, aged 59, January 18, at his 
home in Washington, D. C. Dr. Burnett had been ill 
with an organic affection of the heart for some months, 
but the immediate cause of death was edema of the 
lungs. He was graduated from Bellevue Medical Col- 
lege Hospital in 1870, and later took a postgraduate 
course in ophthalmology in Europe. In 1879 he was 
appointed to a professorship in the Georgetown Uni- 
versity, Washington, D. C, which post he held up to the 
time of his death. He also held a professorship in the 
Washington Postgraduate Medical School ; was one of 
the founders of the Emergency Hospital, Washington, 
and for many years president of the attending staff of 
physicians ; also a member of the staffs of the Provi- 
dence and of the Children's Hospitals, and ophthalmic 
surgeon to the Central Dispensary in Washington. He 
was a member of the Washington Academy of Science 
and various other medical societies. He was the author 
of a " Treatise on Astigmatism," and contributed many 
chapters to textbooks on diseases of the eye and ear. 

John Martin Kliuck, aged 22, January 19, from 
malignant scarlet fever, at the Kingston Avenue Hos- 
pital for Contagious Diseases, Brooklyn, N. Y. He was 
a recent graduate, having obtained his degree at a 
southern college. Coming to New York to obtain hos- 
pital experience, he entered the Contagious Hospital on 
January 8. 

Frank H. Caldwell, January 20, from Bright's dis- 
ease, at his home in Tampa, Florida. He was gradu- 
ated from Jefferson Medical College, Philadelphia, in 
1880, and had been in practice in Florida for over 20 
years. For a number of years he was chief surgeon for 
the Plant System in Florida. 

William B. Neftel, aged 76, January 20, at his 
home in New York. He was graduated from the Uni- 
versity of St. Petersburg in 1852. During the Crimean 
war he served a.s surgeon to the Russian Imperial 
Guards, and in 1865 came to the United States. 

James H. DeWolf, January 17, at his home in 
Baltimore, Md. He was graduated from the University 
of Pennsylvania in 1878, later taking a postgraduate 
course in Europe. He had practised in Baltimore for 20 
years. 

Hannibal Hamlin, aged 58, .lanuary 19, from peri- 
tonitis, at his home in Orono, Maine. He was gradu- 
ated from the Medical School of Maine, at Bowdoin 
College, Brunswick, Maine, in 1872. 



122 AMERICAN MeDICINKI 



THE PUBLIC SERVICE 



[JAnnABY 27, 1906 
Vol. XI, No. 4 



Simon G. Miller, aged 59, was run over by a train 
and instantly Ifilled, January 17, near his home at Pa- 
latka, F'la. He was graduated from Hellevue Medical 
College in 1874. 

Richard Armstrong' Heath, aged 42, of Buffalo, 
N. Y., January 17, at the St. Luke's Hospital, Buffalo. 
He was graduated from Edinburgh University in 1892. 

Isaac Cooper, .January 17, from apoplexy, at his 
home in Trenton, N. J. He was graduated from Hahne- 
mann Medical CJollege, Philadelphia, in 1868. 

William E. Hodges, January 16, at his home in 
Ellicott City, Md. He was graduated from the Univer- 
sity of Maryland School of Medicine in 1856. 

Frank Parker Perry, aged 55, January 14, at his 
home in Bucksport, Me. He was graduated from Long 
Island Hospital College, Brooklyn, in 1873. 

Henry St. John, aged 80, January 16, at his home 
in Alexandria, La. He obtained his medical degree in 
England. 

Philip S. Orndorft", aged 72, .January 16, from 
paralysis, at his home in Rio, Hampshire county, 
W. Va. 

Walter Hurt, aged 30, of Belmont, Ontario, Cana- 
da, January 18, at the General Hospital, Belmont. 

Dr. Emes, January 15, from diabetes, at his home 
in Niagara Falls, N. Y. 



THE PUBLIC SERVICE 



Changes in the Medical Corps of the U. S. Army 

for the week ended January 20, 1906 : 

First Lieutenant John A. CiiARK, assistant surgeon, 
leave granted December 19 is extended one month. — Al- 
bert H. Ebee, contract surgeon, will proceed from St. 
Clair, Mich., to Fort D. A. Russell and report to the 
commanding officer, sixth battalion of field artillery, for 
duty to accompany that command to the Philippine 
Islands. Upon arrival at Manila Contract Surgeon Eber 
will report to the commanding general, Philippines Di- 
vision, for assignment to duty. — First Lieutenant James 
BouRKE, assistant surgeon, is relieved from further duty 
at Fort Sheridan, 111., and from temporary duty at the 
medical supply depot. New York City, to take effect 
upon the expiration of his present leave, and will report 
for duty as surgeon of the transport Kilpatrick. — The 
following changes of station of medical officers are 
ordered : Captain G«orge J. Newgarden, assistant sur- 
geon, will report at Cuartel Meisic, Manila, for duty, re- 
lieving First Lieutenant Gideon McD. Van Poole, assist- 
ant surgeon, who will proceed to Camp McGrath, 
Batangas, and report for duty. — First Lieutenant James 
F. Hall, assistant surgeon, having completed the duty 
for which he was ordered, will return to his proper sta- 
tion. Leave for ten days is granted Lieutenant Hall. — 
First Lieutenant George H. Scott, assistant surgeon, 
is relieved from duty in the transport service, and will 
proceed to Fort Duchesne for duty. — Henry M. Hall, 
contract surgeon, now in San Francisco, Cal., will pro- 
ceed to his home, Cedartown, Ga., for annulment of eon- 
tract. — Henry M. Hall, contract surgeon, is granted 
leave for two months. — Major Edgar A. Mearns, sur- 
geon, is relieved from duty in the Department of Luzon 
and will report to the chief surgeon of the Philippines 
Division for duty in his office. — First Lieutenant Robert 
L. Carswell, assistant surgeon, is granted leave for one 
month and ten days, with permission to visit China and 
Japan, effective about January 15. — Orders relieving 
Major Edgar A. Mearns, surgeon, from duty in the de- 
partment of Luzon and assigning him to duty in theoffice of 
the chief surgeon of the Philippines Division are revoked. 
— Major Henry S. T. Harris, surgeon, having arrived 



on the transport Sherman, will proceed to Iloilo, Panay, 
reporting to the commanding officer. Department of the 
VLsayas, for duty. — First Lieutenant Wii,liam E. Vose, 
assistant surgeon, having arrived on the transport Sher- 
man, will proceed to Borongan, Samar, for duty. — First 
Lieutenant John W. Hanner, a.ssistant surgeon, is re- 
lieved from duty at the division hospital, Manila, and 
will report to the commanding officer, transport Seward, 
for duty thereon as transport surgeon, with station in 
Manila, vice First Lieutenant Charles F. Morse, assistant 
surgeon, relieved. — Lieutenant Colonel Wii,liam H. 
Corbusiek, Deputy Surgeon-General, will be relieved 
from duty in the Philippines Division in time to pro- 
ceed on the transport scheduled to sail about January 25 
to San Francisco, Cal., reporting by telegraph to the 
military .secretary of the army for instructions. — Major 
William D. Crosby, surgeon, will be relieved from 
duty in the Philippines Division in time to proceed on 
the transport scheduled to sail about February 15 to San 
Francisco, Cal., reporting by telegraph to the military 
secretary of the army for instructions. — First Lieutenant 
William T. Davi.s, a.ssistant surgeon, is granted leave 
for three months, with permission to return to the 
United States via Europe, effective upon his relief from 
duty in the Philippines. — First Lieutenant Charles N. 
Barney, assistant surgeon, now at tlie general hospital, 
Fort Bayard, N. M., will report for duty. — Captain 
Thom.\s J. Kikkpatkick, assistant surgeon, having 
reported his arrival at San Francisco in compliance with 
orders heretofore issued, will proceed to Fort Moultrie, 
S. C, and report in person to the commanding officer fori 
duty. — Ja.s. B. Hallwood, contract surgeon, is grantedi 
leave for two months. — First Lieutenant William H. 
Moncrief, assistant surgeon, having reported his ar- 
rival at San Francisco, Cal., in compliance with orders 
heretofore issued, will proceed to Fort McPherson for 
duty. 

Changes in the Public Health and Marine-Hos- 
pital Service for the week ended January 17, 1906 : 

L. L. Williams, surgeon, directed to proceed to 
Wilmington, N. C, for the purpose of making an inspec- 
tion of the station. — W. G. Stimp.son, passed assistant 
surgeon, gwcnted leave of absence for one month from 
January 15, 1906.— L. E. Cofer, passed assistant sur- 
geon, granted leave of absence for 20 days from January 
19, 1906. — Taliaferro Clark, passed assistant sur- 
geon, directed to proceed from Philadelphia to Easton, 
Pa., for special temporary duty, upon completion of 
which to rejoin station.— T. F. Richardson, passed 
assistant surgeon, granted leave of absence for seven 
days from January 13, 1906.— W. W. King, passed as- 
sistant surgeon, relieved from duty at San Juan, P. R., 
as chief quarantine officer, and directed to proceed to 
Washington, reporting at the Bureau for orders.— J. M. 
Holt, pa.s.sed assistant surgeon, granted leave of absence 
for two months from January 15, 1906, on account of 
sickness. — J. T. Burkiialter, passed assistant surgeon, 
granted leave of absence for one month from January 
24, 1906. — L. P. Gibson, acting assistant surgeon, granted 
six days' leave of ab.sence from January 16, 1906.— W. L. 
Stearns, pharmacist, granted seven days' leave of 
absence from January 13, 1906, under the provisions of 
paragraph 210 of the regulations. 

Changes in the Medical Corps of the U. S. Navy 

for the week ended January 20, 1906 : 

John E. Page, passed assistant surgeon, ordered to 
the Franklin, Norfolk, Va.— H. G. Beyer, medical in- 
spector, detached from the Wisconsin and ordered to the 
Ohio. — G. H. Barber, surgeon, detached from the Ohio 
and ordered to the Wisconsin. — J. C. Thompson, sur- 
geon, detached from the Lawton and ordered to the Cin- 
cinnati. — W. H. BuciiER, surgeon, detached from the 
Cincinnati and ordered to the Lawton. 



Jancary 27, 1906T 
Vou XI, Ho. i J 



BOCIETY REPORTS 



rAHEBICAH MBDicnrB I 23 



SOCIETY REPORTS 



WESTERN SURGICAL AND GYNECOLOGICAL ASSO- 
CIATION. 

Fifteenth Annual Meeting, Held in Kansas City, Mo., 
December 28 and 29, 1905. 

[Specially reported for American Medicine.] 
[Concluded from page S9.] 

The Choice of Ligature and Suture Material in 
the Surgery of the Peritoneum. — H. G. Wktherill 
(Denver, Colo.) stated, among other things, that he 
would no longer use nonabsorbable ligature or suture 
material for purely serous surfaces. The absolute steril- 
ization of catgut wa-s no longer difficult, and it was now 
realized that socalled catgut infections usually had their 
origin in a contamination of the gut through handling 
or in allowing it to come in contact with unclean sur- 
faces or substances in or about the wound. Then, too, 
the chromicizing process prolonged the life of even the 
smaller strands to any desired time, providing the' 
mucous surfaces or secretions were not in contact with 
it. These features made of catgut an ideal suture and 
ligature material for intraperitoneal use, and all that 
became necessary was the exercise of due care and skill 
in the selection of the catgut and the application of 
sutures and ligatures and the making of knots. So far 
he had had the good fortune never to have had a sec- 
ondary hemorrhage or other accident from the use of 
catgut, either in the way of a slipping knot or a too 
rapid absorption, and he believed this immunity from 
accident to have been due to the exercise of extreme 
care in its application. For about three j'ears he had 
had great satisfaction in the use of the Downes electro- 
thermic cautery clamp in selected cases, thus doing 
away with all ligature and suture materials around ped- 
icles. For vaginal hysterectomy, particularly in cancer 
of the uterus, it wa.s ideal. It promoted rapidity and 
safety in the work, and without doubt gave much 
greater security against the danger of recurrences in 
early cases. There was, in his experience and judgment, 
no doubt that patients operated upon with the Downes 
clamp by either the vaginal or abdominal routes had 
smoother and more rapid recoveries, and above all, a 
very noticeable freedom from the intense pain and back- 
ache so common after all pelvic operations, when the 
terminal nerves of this region were left for days or 
weeks in the bight of a securely tied ligature or closely 
applied suture. He had had one or two experiences 
with the Downes clamp, however, which led him to 
believe that there was increased danger from thrombo- 
sis and embolism after its use, occasionally occurring 
several weeks after operation, and until this doubt was 
settled, he would be most careful in the selection of the 
cases upon which it was used. 

Talipes Calcaneus. — A. V. Joxas (Omaha, Neb.) 
, described a plastic operation for the permanent relief of 
cicatricial talipes calcaneus. 

The Treatment of Varicose Veins. — C. H. Mayo 
(Rochester, Minn.) said that the various operations in 
use at the present time were necessary, from the diverse 
conditions and symptoms manifested by the disease. 
The condition was probably from a defect in the vein 
Willis, valves, or enervation. The Trendelenburg opera- 
tion was deservedly popular, especially, for cases of 
vicious veinous circle of the deep and superficial vein of 
the thigh. Enucleation of the veins in a subcutaneous 
manner through several short incisions was a satisfac- 
tory treatment for the majority of cases. The subcu- 
! ineous removal of the internal saphenous from above 
it the side of and below the knee, by destroying the 
main superficial channel and deep communicating 
^branches, was the best method, accomplishing in one 



operation all that could be obtained by either the Tren- 
delenburg above or the Sehede below. Goerlid's report 
showed 84 fe of operations as satisfactory and 16 ^ as 
failures. From experience in 184 cases this seemed a 
fair statement of the late results from the various 
methods employed at present, except in the percentage 
of failures; 16^ was too high, as many of those not 
satisfactory were much improved over their former 
condition. 

[To be continued.] 



THE SOUTHERN SURGICAL AND GYNECOLOGICAL 
ASSOCIATION. 

Eighteenth Annual Meeting, Held in Louisville, Ky., 
December 12, 13, and 14, 1905. 

[Specially reported for Ameriean Medicine.] 
[Continued from page 8S.] 

Foreign Bodies in the Esophagus. — Stuart 
McGuiRE (Richmond, Va.) said that the diagnosis of 
foreign body in the esophagus was based on the history 
of the case, the external palpation of the neck, the pas- 
sage of an esophageal bougie, and finally by the use of 
the rontgen ray. The character and location of the 
foreign body being determined, the practical question 
was how to remove it. If it was round or smooth, 
efforts should be made to extract it with forceps and 
probangs, or to make the patient eject it by swallowing 
masses of partially masticated food and then vomiting. 
If it be small, it might seem wise to endeavor to push 
it into the stomach. None of these expedients should 
be tried when the foreign body was pointed, sharp or 
angular. Under modern surgical technic an open oper- 
ation was the safest procedure. There were two means 
of approach, one by an external esophagotomy, the other 
by a gastrotomy, and the selection of the method would 
depend on the location of the impaction. If it was 
opposite the cricoid cartilage, an esophagotomy should 
be done ; if it was below the level of the supraclavicular 
notch, then gastrotomy should be performed. As an 
illustration of the operations of esophagotomy and gas- 
trotomy, he reported two cases. In one, the patient, 
aged 10, while playing with a glass stopper, put it in her 
mouth and swallowed it. It lodged in the esophagus 
opposite the cricoid cartilage and produced complete 
obstruction. The foreign body was removed by an 
external esophagotomy. The second case, a baby aged 
7 months, while being dressed, seized an open safety-pin 
and put it in its mouth. The mother, in her efforts to 
remove it, pushed it first into the fauces and then into 
the esophagus. The pin was removed in this case by 
a gastrotomy. 

Discussion. — J. Wesley Long (Greensboro, North 
Carolina) narrated the case of a forty-six-day-old infant 
who had swallowed an open safety-pin ; the pin lodged 
in the esophagus opposite the two cricoid cartilages. A 
radiograph, however, showed that the point of the pin 
was below the arch of the aorta. It produced constric- 
tion of the esophagus where the left bronchus crosses it, 
and the pin was removed by an external esophagotomy 
without any shock. He thought there were some cases 
in which this operation was preferable to gastrotomy. 
W. S. GoiiDS.MrTH (Atlanta, Georgia) mentioned the 
case of a patient who had swallowed the concave part of 
a dental plate, which lodged in the esophagus and was 
retained there for a period of four months. At the end 
of this time patient was very much emaciated and weak. 
After locating the foreign body, efforts were made to 
extract it with forceps, but this could not be done. It 
then occurred to him to try Bull's method of attaching 
a series of sponges to a long silk ligature and using an 
esophageal bougie, passing it out through the mouth 
and leaving in position the series of sponges. After 
attaching the bougie, it was a simple matter by a few 
sweeping movements backward and forward to push the 



124- [American Medicine 



CORRESPONDENCE 



CJANDARY 27, ]9(Hj 
Vol,. XI, No. i 



foreign body into the stomach and extract it through 
the gastrotomy opening. The foreign body was of such 
consistency that the rontgen ray was of no aid. H. A. 
RoYSTER (Raleigh, North Carolina) rei)orted the case of 
a child, aged two, who, two weeks previously to his 
seeing the case, had swallowed the wheel of a tin 
toy wagon. The child was able to swallow liquids, but 
not solids. During this time it subsisted on milk and 
liquid food. He used a medium-sized shotted semielas- 
tic bougie for the purpose of an examination ; this passed 
into the esophagus, met with some resistance, after 
which he was enabled to pass it farther without obstruc- 
tion apparently. After applying a mouth-gag he was 
enabled to extract the foreign body with an esophageal 
forceps. The foreign body lay transversely across the 
esophagus. ,J. Shelton Hoksley (Richmond, Vir-' 
ginia) said if a foreign body could not be removed 
by ordinary means, no time should be lost in resort- 
ing to early operation. He reported the case of 
a child who had swallowed a camel from a grab bag. 
The child put it into its mouth ; it was situated 
a little lower than the level of the larynx. He tried 
to extract it by several different methods, but was 
unsuccessful. He saw the child on the fourth day after 
it had swallowed the foreign body; did an esophagotomy, 
and removed it with comparative ease. The esophagus 
was injured and gangrenous. Septic symptoms devel- 
oped, and the child died on the fourth day following the 
removal of the foreign body. He thought the child's 
life might have been saved by an earlier operation. 
Charles M. Rosser (Dallas, Texas) reported two cases 
of foreign bodies in the esophagus. In one, the foreign 
body, an ordinary pin was located by the rontgen ray, 
but could not be removed by ordinary means. Two- 
thirds of the pin was buried, but with the aid of the 
fluoroscope the pin was caught by its head, and with for- 
ceps, extracted. In the other case, a child, a nickel was 
located within two or three inches of the cardiac end of 
the esophagus. Gastrotomy was performed, and the for- 
eign body extracted. The child lived about 6 or 8 hours, 
then died, apparently without shock. Rurus B. Hall 
(Cincinnati, Ohio) reported the case of a child of a physi- 
cian, five months old, who swallowed a safety-pin an 
inch and a half long. It remained in the esophagus for 
a time, but at the end of 24 or 36 hours the symptoms 
caused by its presence disappeared. The child was able 
to take the breast and thrived well. A rontgen-ray pic- 
ture was taken which disclosed an open safety-pin in the 
pyloric end of the stomach. Parents declined an opera- 
tion for its removal until unfavorable symptoms devel- 
oped. Several rontgen-ray pictures were taken ; but the 
child did not develop any unfavorable symptoms refera- 
ble to the presence of the safety-pin. When the child 
was 26 months old, it passed the pin by the natural 
route. The child is now 7 years old. W. D. Haggard 
(Nashville, Tenn.) related the case of a child 18 months 
old, who swallowed a pin, the head of which was as 
large as a cherry seed. The child developed cough, and 
the presumption was that the pin had lodged in a bron- 
chus. A rontgen-ray picture threw very little light in 
regard to the presence of the foreign body. The pin 
appeared to be in a bronchus, with its head down and to 
the left. The child had little or no pulmonary symp- 
toms, to justify him in doing an operation. At the end 
of 10 days another rontgen-ray picture was taken, but 
the symptoms were so slight that operation was deferred. 
Four days later another radiograph was taken, which 
failed to locate the pin, and shortly after this the child 
passed the pin by the natural route. McGuire, in clos- 
ing the discussion, said no hard and fast rules could be 
laid down as to whether esophagotomy or gastrotomy 
should be done in a given case. Of the two operations 
he preferred to do gastrotomy. It seemed easier and the 
after-treatment was simple. If it was equally appli- 
cable, it was the method to be adopted. 

[To be continued.] 



CLINICAL NOTES AND CORRESPONDENCE 

rcommnnlcatlons are Invited for thU Department. The Editor Is 
not responsible for the views advanced by any contributor.} 



THE EFFECTS OF TROPICAL LIGHT.' 



MAJOR CHARLES E. WOODRUFF, 
Surgeon, United States Army, Plattsburg Barracks, New Yorlc. 

To the Editor of American Medicine .-—I enclose a 
copy of a letter sent to the Journal of Tropical Medicine 
to resent a misleading book review containing many 
nonsensical misquotations. This is a matter which 
vitally touches every physician in the civilized world. 
When a book is reviewed it is essential that the state- 
ment of its contents shall be correct, no matter what 
may be the reviewer's opinion of their value. It is 
dasired to call wide attention to this dreadful injury to 
medical journalism, and I would be pleased to have you 
publish the letters, to put upon such practices the stamp 
of stern disapproval. 
To the Editor of the Journal of Tropical Medicine : 

In reply to your letter expressing a desire to publish 
an answer to Colonel G. M. Giles' adverse criticism 
(Journal of September 1) of the theory that light is a good 
stimulant if taken in moderation, but harmful in excess, 
I must say that I tind it extremely difficult to do so 
without quoting my book in full. He has said so many 
things which are not found in the book that it is quite 
evident he has not read it understandingly. His intem- 
perate remarks also show such a lack of the judicial 
temperament needed in a reviewer as to detract from 
their value as controversial, even if they were correct. 
A discovery which runs counter to long excepted 
theories is rarely received without strong protest from 
the unprogressive element and the senile. It has been 
said that Jenner's theory was never accepted by any 
physicians who were over 40 at the time of its promul- 
gation, and we all know the dark history of the attacks 
upon the theory of the infectious origin of puerperal 
septicemia, attacks made by scientists entrenched in 
official positions. New ideas must wait for recognition 
until the young men grow into authority. There is 
much truth, then, in the old saying that it requires 20 
years for a true but heretic idea to become orthodox, 
excepting, of course, those which emanate from the 
orthodox teachers themselves. Yet it is astounding that 
such an important matter in tropic hygiene as von 
Schmaedel's theory of the use of skin pigmentation 
should not have been put to practical use by English 
surgeons in India in all these years since it was first 
announced. It is really a great blot upon tropic med- 
icine and its alleged progressiveness. 

Colonel Giles is naturally reluctant to confess that he 
has been wrong all his life in advocating to his patients 
a harmful degree of light, and that's where the shoe 
pinches in America, too. His statement, that something 
which is new to him is mischievous, proves that the 
British nation is to be congratulated upon its wisdom in 
establishing a retired list for those who have been bom- 
barded bv tropic light too many years. I am very 
much of the opinion that the American plan of keeping 
troops but two years in the tropics is the wisest, for I 
am afraid that twenty years in its dazzling light would 
entirely blind us to its dangers, and make it necessary for 
us also to retire after that length of service for escape to 
cloudier climes to educate our children. 

Two Frenchmen have recently written upon the 
subject of the damage done to living protoplasm by 
light, and their articles in Cosmos and />« Nature are 
being quoted in America. Perhaps some English 
writers will now begin "to set up and take notice' 

rpublished by Rebman Company, 1123 Broadway, New 
York ; Rebman, Ltd., 129 Shaftesbury Ave., W. C, London. 



January 27, 1906"] 
VOL. XI, No. 4 J 



CORRESPONDENCE 



fAMBRICAN MEDICrNB 125 



also. It won't do to let the French steal our thunder 
this way. 

In regard to the general law that in Europe the pro- 
portion of brunets and the degree of their pigmentation 
increase with the mean annual sunshine, it is only 
necessary to comjpare Bartholomew's maps of cloudiness 
and Ripley's maps of complexions to see that it is a law. 
The Colonel does not seem to have done this. There are 
other laws of course— such as the increase of blondness 
with elevation (excepting on treeless plateaus) and its 
increase with latitude, but these do not alter the fact 
that the most blonds are in the cloudiest places of 
Europe. Colonel (files states that he can see no such law 
in the British Isles. His view is so intensely provin- 
cial that, as an American, I rise to remark that his little 
islands occupy but a very small spot on the map of 
Europe. What they reveal as to clouds and com- 
plexions has no bearing upon a law which takes in the 
British nation's average as only one very small item in 
the whole. The Colonel apparently thinks that Europe 
consists of London and a bit of continent around it. 

His statements that the speculations on the origin of 
blondness are based on the old ideas when ethnology was 
regarded mainly from the philologic standpoint, is the 
exact opposite of the stated facts, which he has evidently 
overlooked. I am sorry also to see that he has not kept 
in touch with the newer anthropology, which has so 
radically modified the old ideas of the place of origin of 
the anthropoids and of man. If somechanges of environ- 
ment caused the anthropoids to evolve into man, surely 
no one except Colonel Giles can expect to find the 
anthropoids still there. He cannot have his cake and 
money, too. Man must have originated in some place 
where there are now no anthropoids and that place is not 
in the tropics. The men of the tropics are now generally 
believed to be descendants of immigrant types. He also 
states that it is surprising that negroes should be evolved 
from white men ; I am surprised, too, for it is nowhere 
stated in the book. His surprise that the Aryans were 
blond is quite conceivable, for it is a very old and re- 
sistant theory of some of the most learned anthropologists. 
I also notice his references to blond races in the tropics, 
but need only mention that these types are now known 
to be well pigmented and far from blond. His theory 
that the color of man's retreating rear view was orig- 
inally evolved to make him resemble his background 
while hiding from enemies perhaps, as in the case of 
some of the lower animals, is exhilarating to say the 
least, and adds to the gaiety of nations. Science, with- 
out such humor, is too slow entirely. 

The book mentions that some light is probably neces- 
sary for man, even if it is not needed by the majority of 
the lower animals, and it distinctly states that dark 
houses are harmful, but not as harmful as those which 
are "light baths." It also states that the amount of 
light in a school-room should be sufficient for good 
vision. Nevertheless he says, " regardless of the evil 
effects of eyestrain, he considers light school-rooms 
objectionable, even in temperate climates," an astound- 
ing evidence of a vivid imagination. Where did he get 
it? He also deplores the absence of experiments on the 
relative penetrability of the tissues to light, but as such 
experiments are mentioned, it is evident that Colonel 
<;iies has not even read parts of the book he has the 
erity to criticise. 

This is a dreadful situation for medical literature, 
hat are the professional readers of your journal to ex- 
it in future reviews — truth or miastatement. In the 
.me of tropic medicine I must express regret that a 
rnal devoted to this science should have found space 
an unfair and mischievous article which so greatly 
misquotes, and which then proceeds to demolish ideas 
which are not in the book or theory it purports to re- 
view. More careful study would have prevented this 
'heck to the acceptance of what is now proving to be of 
real importance. It is conservatism with true Anglo- 




Saxon obstruction. The work was sent to Colonel Giles 
to be reviewed, for it is extremely important to learn of 
errors of fact or conclusion in the work, but it is a boot- 
less task to reply to criticisms of what is not said in it. 

I can only recommend to Colonel Giles that he read 
something of the new uviol lamp of Doctor Schott, of 
Jena, a lamp which gives a cold light, devoid of red and 
infrared rays, but rich in* ultra violet. Its deadly ef- 
fect upon living organisms is so startling that he 
should stand aghast at having recommended so much of 
a deadly agent to poor unprotected skins. But as he 
wants ocular proof that a black skin is more opaque than 
that of a blond Scandinavian — a matter most of us con- 
sider axiomatic — I am afraid he is a doubting Thomas, 
who will not believe he has brains because he has never 
seen them. 

I am astounded to learn that the experiment of con- 
tinuous residence of Europeans in the tropics has never 
been fairly tried — shades of Goths and Vandals ! groan 
in your premature graves ! — and I am doubly astounded 
that I have said " that big men are found only in cold, 
gloomy climates." I thought that they were found in 
other places besides Great Britain. He should study the 
great natural law described in Science, November 24, 
1905, by J. A. Allen, that in nearly every genus of 
mammal or bird the species nearest the equator is 
smallest, and in every species the individuals decrease 
in size toward the equator also. 

I also note that Colonel Giles in his own book on the 
tropics is a strong advocate of the belly-band to prevent 
intestinal infections. The great majority of American 
physicians have a suspicion that this is the wrong place 
for a filter, and that it has no effect whatever on cholera 
vibrios we swallow. So it is evident that we look at the 
world through different eyes — perhaps in America we 
have more light, which might injure us, no doubt, but 
we die seeing, and after all that might be better than a 
long ignorant life in the darkness of London's fogs. The 
statement that Persia is perhaps the sunniest country in 
the world is sure to make our Southern California citi- 
zens froth at the mouth. Away with such heresy ! — we 
have a monopoly on sunny climates — it's our 'obby. 

Colonel Giles also states that sufficient prominence is 
not given to the fact that light is therapeutically useless 
except in quite superficial lesions. This is a well-directed 
criticism and I am truly sorry for the mistake. To be 
sure, the fact is mentioned several times — which was con- 
sidered enough for American readers — but if I had real- 
ized the darkness of London and the diflftculty of seeing 
what is mentioned several times, I would have printed 
it on every page of the edition intended for London 
consumption. 

"In conclusion, let me express to" Colonel Giles 
" my regret in being unable to find myself in agreement 
with" his dreadful mistakes, "6m< magna est Veritas et 
prcevalebit is, it cannot be doubted, as much his guiding 
principle, so that I feel sure he will in no way resent 
what, after all, is" merely the defense of a great law of 
extreme value to the newer tropic medicine for which 
he will never have further practical use in London fogs. 

It is to be hoped that the British troops in India will 
not take as many generations to learn and profit by this 
law as they were in discovering the cure for scurvy or in 
learning that uniforms suitable for Scotland are not quite 
the thing for equatorial regions. We expect to take the 
lead, for as early as 1950, if we live that long, we will 
find that Americans in the tropics are taking note of the 
matter. Many of them have not even heard of it yet. 
Somewhere along in the twenty-first century our clima- 
tologists will hear of it — at present they do not know 
anything of this part of their special science. Their 
journals do not mention it, and those men who review 
climatologic literature for scientific journals haven't yet 
waked up. The weather experts are beginning to stir 
and may yawn soon. Perhaps along in the next gener- 
ation the school of tropic medicine in London fogs. 



126 



American Mkdicini4 



CORRESPONDENCE 



rjANUABY 27, 1906 

LvoL. XI, No. i 



will look up from the microscopes long enough to study 
the effects of tropical light, so that its students will go 
forth knowing something of the subject. Of course they 
haven't sufficient light in London to investigate the 
matter, but they might read of investigations made 
elsewhere — perhaps. 

The medical profession working in the tropics should 
not wait for the official scientist but study the matter at 
once. Colonel Giles himself should try to explain why 
tuberculosis is best cured where the sun never shines, 
and why the death and sick rates of American soldiers 
are at their lowest in the cloudiest and rainest parts of 
this country as shown in the last report of the Surgeon- 
General. If it is due to protection from too much light, 
it is really next to murder to advocate the old theory of 
excessive exposure of our patients. Perhaps it is merely 
perversity which induces them to die in sunny climes, 
to spite our old theories. 

I do not remember ever having read a review con- 
taining so many garbled and erroneous statements as 
are found in the four columns written by Colonel Giles. 
The matter should be resented by the medical profession, 
as the injury done to it deserves the severest condemna- 
tion. In a letter Colonel Giles says: "But I don't 
count reviews much— I used to earn an odd guinea now 
and again at that, when I was but a student, and I often 
grin at the memory of the way I used to criticise what I 
understood nothing of. Of course, unless the editor 
marked [ormailed,C.E.W.] it for damning, I was always 
on the safe, laudatory side." In his old age is Colonel Giles 
still deliberately criticising what he understands not, or 
is he unable to understand it, or did you, Mr. Editor 
mark the matter for damning? In either case, the 
Journal of Tropical Medicine is in a dreadful position, if 
it is doing anything to continue the destruction of the 
health of British soldiers in the tropics. A little more 
editorial discretion would have been a benefit to that 
part of your nation compelled to leave the protection of 
the clouds and fogs they love so well, and reside a short 
time in the tropics. 

There was a time, Mr. Editor, when Englishmen 
could see nothing good in America. The pains left by 
the bruises of our Revolution lasted a long time, but we 
had hoped that the dependence of England upon 
America for her food had smoothed your ruffled feathers. 
Our statesmen prate of our new international friendship 
— our politicians deny it. Are the latter correct? Is 
there still a remnant of the old hostility which gives you 
such a high degree of mental astigmatism that you can 
see nothing straight in America? If there is, its your 
own loss. May God help your soldiers in the tropics, 
if your doctors won't. 

Dr. Allan McLane Hamilton, one of the leading neu- 
rologists of America, writes me: " 1 can confirm what 
you say about the undesirability of a ' sunshiny ' place 
for blonds. For five summers I lived in Capri and my 
experience was that northern people of the nonpig- 
mented type were nearly always ' nervous ' and did not 
do well. When there was a psychopathic temperament 
it was aggravated." . . . "For many years I have 
advocated the use of the darkened room for several hours 
daily, with a few hours of cheerful sunshine (for the 
psychic effect) in my ' rest cases ' and they have im- 
proved when they would not under the conventional 
and popular treatment of ' plenty of sunshine and fresh 
air.' " And yet Colonel Giles has the audacity to inti- 
mate that it is "mischievous" to cure people in this 
way — by removing one cause of the illness. 

It is interesting to note that as early as 1817 the value 
of darkness in the rest treatment of neurasthenic condi- 
tions was noted by a London physician. Dr. G. R. Rowe, 
F.R.C.P., and F.R.C.S., in a little book on hypochon- 
driasis. He did not know neurasthenia by that name — 
many European physicians do not even yet— and he 
mixed up dysentery and other things in his tropic cases 
and made many other curious errors even as late as the 



sixteenth edition in 1860, but that does not alter the fact 
that in his neurasthenic cases he darkened the room to 
exclude " the rays of light from offensively acting upon 
the retina, and consequently, the sensorium commune " 
(page 43, second edition). This hint was thrown out 85 
years ago and is not a^'ted on yet— pretty good record for 
English physicians in India. It is to be hoped that they 
will hear of it in the next 85 years. 

The Indian Medical Gazette of November, 1905, con- 
tains an editorial on the subject, and it must be consid- 
ered pernicious by Colonel Giles. The younger element 
in Calcutta is waking up nicely — they have more light 
to see things than those in London. A few actinometric 
observations were made in Russia in 1891 and 1892, but 
beyond these and the observation of the average and 
total cloudiness, practically nothing is recorded as to the 
total amount and intensity of the light of any place in 
the world — a most astounding evidence of the lack of 
progressiveness of climatologists and meteorologists. 
Indeed, among the dozens of reviews of the book, the 
only flippant and childish one is by a certain C. Meri- 
wether, in the Geographic Magazine of January, 1906. 
It has a value, nevertheless, as it is so stupid and shows 
such dense ignorance of the matter as to explain in full 
the backwardness of climatology. His belligerency can 
be excused on account of his name — it is a pugilistic clan 
— but his dreadful misstatements are unpardonable. It 
is fitting that such nonsense should appear in the Geo- 
graphic Magazine, whose editorial staff consists mostly 
of official scientists — a class notorious for its hatred of 
new ideas from outsiders. Hundreds of illustrations 
could be given of their opposition to scientific progress. 
Cuvier, when shown human fossils, pitched them out 
of the window, the English astronomer Royal con- 
temptuously refused to look for the planet whose position 
was accurately calculated by an outsider, Owen marred a 
long career as a naturalist by opposition to organic evo- 
lution and by underhand denial of its evidence, and now 
comes that great expert— merry Meriwether, weather 
expert— with his inability to learn something new. We 
can almost hear him say " The sun do move." He's in 
good company with Cuvier and Owen, and the medical 
profession will treasure his review as a fine study of a 
reviewer's psychologic abnormalities. As the new ideas 
are being accepted, it is interesting reading matter 
already. 

A CHISEL FOR OSTEOPLASTIC WORK ON THE 
SKULL. 



JOHN EGERTON CANNADAY, M.D., 

of Paint Creek, W. Va. 

Surgeon in Charge, Sheltering Arms Hospital, Paint Creek, W. Va. 

During recent years various operations for the ex- 
posure of portions of the brain by means of the osteo- 
plastic flap method have been devised, and as time has 
gone on, have become deservedly popular. In outlin- 
ing these flaps after the soft structures have been cut 
through, the chisel, as a simple, straight-forward instru- 
ment, has perhaps been used more than any other 

THE KNY-SCHEcPER CO. N.V. 




device. With the ordinary chisel, in cutting a groove 
in the skull, one has to cut down on one side, then on 
the other to complete the channel. I have sought to 
expedite matters by devising a chisel with a V-shaped 
cutting edge. This makes a clean cut groove and saves 
time. 

This instrument was made up for me by the Kny- 
Scheerer Company and is quite satisfactory in practice. 



January 27, 19061 
Vol. XI, No. 4 J 



PUERPERAL INFECTION 



[AMERICAN HEDICINK 127 



ORIGINAL ARTICLES 



SOME PROBLEMS IN THE DIAGNOSIS AND TREAT- 
MENT OF PUERPERAL INFECTION.' 

BY 

B. C. HIRST, M.D., 
of Pbiladelphla. 

There is no problem in the whole realm of gynecology 
more important than the prevention, diagnosis, and 
treatment of puerperal infection. Pelvic and abdominal 
tumors, injuries of the birth canal, displacements of the 
pelvic viscera, nonpuerperal pelvic inflammations and 
the operative teehnic required for their treatment 
are subjects on which little remains to be said. 
But discouragingly little progress has been made 
in the prevention, the recognition and the cure 
of puerperal infection, though in frequency and 
danger it stands first, I think, among the diseases 
of women. Several factors have contributed to retard 
the advance in this department of gynecology that might 
"have been expected in these days of asepsis. A large 
'proportion of the women delivered in the cities are 
attended by midwives, with no knowledge of surgical 
cleanliness. A very large number of parturient patients 
are attended by physicians who practise no other branch 
of surgery but obstetrics and who have not therefore a 
clear conception of aseptic surgical teehnic. The sur- 
roundings and attendants of many patients make surgi- 
cal or even ordinary cleanliness impossible. A certain pro- 
portion of childbearing women have an infected genital 
canal before labor begins, and may become septic after- 
ward although the medical attendant, the nurse and the 
surroundings at the time of labor are irreproachable. It is 
not strange, therefore, that puerperal sepsis in general 
practice seems as rife almost as it ever was and that the 
advent of the antiseptic and of the aseptic era has had 
nothing like the effect in reducing morbidity and mor- 
tality after childbirth that it has had in other surgical 
procedures. Consequently the diagnosis and treatment 
of puerperal infection is an ever present problem in med- 
ical practice, usually fraught with anxiety, often obscure 
and difficult in the extreme. The subject is too large to 
discuss in extenso. I propose, therefore, to confine this 
article to a few phases of it, viz.: the bacteriologic 
examination of infected women as a means of precise 
and accurate diagnosis; the influence the results of this 
examination should have upon prognosis and treatment ; 
the treatment of infection after labor by instrumental 
exploration and evacuation of the uterus; the present 
status of antistreptococcic serum as a curative agent; 
and, the lessons taught by practical experience in the 
operative treatment of puerperal sepsis by pelvic and 
abdominal surgery. These are the phases of the subject 

h 'if^1^=^®'°''® *'^^ Cincinnati Academy of Medicine, Decern- 



on which at present there is the greatest difference of 
opinion. 

The Bacteriologic Examination as a Means of Pre- 
cision in Diagnosis. — During the 19 years since Conner 
and Doderlein began the study of bacteria in the genital 
canal, there has been an enormous amount of work done 
in this field with the most disconcerting differences in 
results. As is well known, the following diverse opinions 
have their advocates: (1) The vagina is normally the 
habitat of a nonpathogenic bacillus, which is not only 
nonpathogenic but is actually inimical and destructive 
to pathogenic microorganisms; (2) the vagina may con- 
tain pathogenic microorganisms of diminished virulence, 
but capable under certain conditions of regaining their 
original virulence; (3) the vagina may contain any of 
the pathogenic microorganisms with their usual toxicity; 
(4) the vagina and cervical canal may contain micro- 
organisms, nonpathogenic and pathogenic, but the uter- 
ine cavity, both in the nullipara and in the puerpera, is 
sterile; therefore if pathogenic microorganisms are 
found in the uterine cavity, the woman is infected; if the 
lochia after childbirth taken from the uterus are sterile 
she is not infected; (5) the uterine cavity may contain 
microorganisms of all sorts, including streptococci and 
other pathogenic germs, while the woman is in perfect 
health, the bacteria acting as saprophytes on the mucous 
membrane, not invading the underlying tissues and con- 
sequently not infecting the patient; (6) the uterine cav- 
ity may be sterile in the puerperiiim, but the patient may 
be desperately infected, the infection having originally 
occurred in the endometrium, but all trace of the infect- 
ing microorganism having disappeared from the original 
site of infection.i It is highly desirable for the practical 
physician seeking the aid of laboratory methods'in diag- 
nosis and treatment, that the truth should be elicited as 
speedily as possible from these apparently irreconcilable 
differences of opinion. For example, if it is tnie, as a 
number of specialists claim it is, that the uterine cavity 
in the puerperium is always sterile in the normal case; 
is always the seat of pathogenic microorganisms in an 
infected case; if the presence of pathogenic microorgan- 
isms in the uterus is a sure sign of puerperal infection ; 
if their absence from the uterine cavity is a sure sign 
the woman is not infected, no matter what her symptoms, 
then the diagnosis of puerperal infection becomes one of 
the simplest problems in medicine and uterine cultures 
must be made in every doubtful case to solve it definitely. 
When this proposition was first advanced some,years ago 
it seemed so convincing and logical that I adopted the 
method with enthusiasm, but it soon appeared unrelia- 
ble. In demonstrating Doderlein's teehnic to classes of 

'A good review of the literature may be found in tlire© 
recent articles : Brownlee, the "Germ Content of the Uterus 
and Vagina during the Normal Puerperium," Journal of Ob- 
stetrics and Gynecology, Brit. Empire, September, 1905- 
JNatvig, Bakteriologiscbe verhiiltrisse im weiblichen Genital- 
sekreten," Archiv. f. Gyn.. 76 Bd 3 Heft. 1905, and Little, " The 
Bacteriology of the Puerperal Uterus," American Journal of 
Obstetrics, December, 1905, "«"»» ui 



128 American AIedicinkJ 



PUEKPEEAL INFECTION 



C January 27, 1906 
Vol. XI, No. 4 



students, on puerperal women without fever or other 
signs of infection, I was at first astonished and disap- 
pointed to receive reports from the laboratory of patho- 
logic microorganisms in about a third of the normal 
cases, in spite of a scrupulously careful technic in obtain- 
ing the lochia. Similar results have been obtained by 
Stolz, v. Franque, Franz, Burckhardt, Wormser, 
Schauenstein, Little and other competent observers, the 
percentage of infected lochia increasing as the puerpe- 
rium advances. A recent series of observations just 
completed in the Maternity of the University of Penn- 
sylvania^ gave the same results, and in four cases in the 
last six months we have been able to demonstrate that 
the uterine cavity may be germ free although the patient 
has a general streptococcic infection following labor and 
probably originating in the endometrium. If it is true 
that a third or more of fever free puerperal patients may 
have pathogenic microorganisms in the uterus, and if a 
certain (in our statistics, a large) proportion of badly 
infected patients have no pathogenic microorganisms in 
the uterine cavity, it is impossible to place any reliance 
on uterine cultures in diagnosticating puerperal sepsis, 
and to base one's treatment on a diagnosis made in this 
manner is obviously absurd. It would be a great pity, 
however, if twenty years' work on the bacteriology of 
puerperal sepsis should prove of no practical value to the 
clinician. But I do not believe that this will be the case. 
What we wish to know in puerperal sepsis is not whether 
there are pathogenic bacteria in the uterine cavity ; there 
may or there may not be whether the patient is sick or 
well, and no human being can tell whether they are sim- 
ply acting there as saprophytes or not. What we do wish 
to know is whether the system is invaded or not, and this 
information I believe we can obtain with a great degree 
of accuracy by blood cultures. Some six or eight months 
ago Dr. Joseph S. Evans of the Pepper Laboratory sug- 
gested that we begin a study of this subject systemat- 
ically, taking a certain number of fever-free patients, but 
investigating most carefully the patients with symptoms 
indicating infection. 

The following review of his bacteriologic work has 
been kindly furnished me by Dr. Evans ■? 

Of 35 cases which were studied, 25 were febrile and 10 
afebrile — normal puerperium. 

In 26 cases both the blood culture and the intrauterine 
culture were made. 

In 3 cases the blood culture alone was made. 

In 6 cases the intrauterine culture alone was made. 

In 6 cases both methods gave positive results ; of these, 
5 were streptococcic infections and 1 was typhoid infec- 
tion. 

• In obtaining the lochia we have used the tube devised by 
Dr. Wm. R. Nicholson, consisting of a metal tube closed at its 
distal extremity by a lid with a catch ; after this is inserted in 
tiie uterus a curved glass tube is passed through it, the cap is 
sprung loose and the glass tube enters the uterus uncon- 
taminated. 

2 The detailed account of the technic employed and the 
results obtained will shortly be published by Dr. Evans in the 
Medical Bulletin of the University of Pennsylvania. 



In 4 cases the blood culture gave positive and the 
intrauterine cultures negative results; of these 4 cases 
one patient was operated upon and multiple abscesses of 
the wall of the uterus were found. The endometrium 
was normal. One patient developed a severe streptococ- 
cic infection within a few hours after delivery, though 
she had never been examined at all. There was appar- 
ently a recovery by crisis after the use of antistreptococ- 
cic serum; a recurrence of S5rmptoms after a five days 
remission with negative blood and uterine cultures, and 
ultimately a perfect recovery. One patient had a mild 
case of infection, subsiding spontaneously after a few 
intrauterine douches. It was the sort of case that clin- 
ically and as a result of uterine cultures would have 
been regarded as sapremic, but the blood cultures showed 
systemic infection. One patient had a virulent strep- 
tococcic infection with intraperitoneal suppuration, sup- 
puration of the psoas muscle, suppurative nephritis and 
ultimately necrosis of the uterus. The woman died and 
the general streptococcic infection was verified at 
autopsy. 

In 3 cases the blood culture alone was made and found 
to be positive. One patient was so weak that the intra- 
uterine culture did not seem advisable. At autopsy, how- 
ever, the streptococcus was isolated from the vagina, 
cervix, endometrium, broad ligament, and peritoneal cav- 
ity. The second patient had rather doubtful symptoms 
of septic infection. There was a history of an intra- 
uterine application having been made following an abor- 
tion. No local manifestations in the pelvic organs could 
be found, therefore an intrauterine culture was not 
taken. The woman made a good recovery. The third 
patient was brought to a private room in the University 
Hospital 30 days after childbirth with an intraperitoneal 
abscess. Abdominal section was first performed, with 
drainage; then vaginal section with drainage of the pel- 
vic connective tissue. Finally a cure by crisis was appar- 
ently secured by antistreptococcic serum. 

In 15 cases both methods were negative; of these 11 
were febrile. 

Six were suspected cases of sepsis. Later developments | 
showed: 1 to be scarlet fever; 1 to be malaria; 1 to be 
uremia; 1 to be salpingitis; 2 to be membranous vagini- 
tis. 

Five were postoperative cases. Local infection was 
found .in each of these in the form of stitch abscesses. 
Three of these were afebrile. Normal puerperium. 

In 2 cases the blood culture was negative and the 
intrauterine positive. One case was postoperative and 
there was a stitch abscess (perineal). One case was 
apparently a normal puerperium. 

In 6 cases the blood culture was not taken and the 
intrauterine culture was negative. These cases were all 
apparently normal and were afebrile. 

Of the 25 febrile cases: 12 positive blood cultures 
showed undoubted sepsis ; 5 gave positive results by both 
methods ; 4 gave positive results by blood culture but neg- 
ative results by intrauterine culture; 3 gave positive 
results by blood culture, no intrauterine culture being 
taken. All of these cases were septic from the clinical 
standpoint. One positive blood culture showed typhoid 
fever. This case looked very much like sepsis. 

Twelve negative blood cultures showed : Six cases to be 
local infections — postoperative. Three cases to be local 
infections — 1 salpingitis, 2 membranous vaginitis. Two 
cases general infection — 1 scarlet fever, 1 malaria. One 
case was uremia. 



Januaky 27, 19061 
VOL. XI, No. 4 J 



PUERPERAL INFECTION 



IAmkkioan Medicink 129 



I 



Of the 10 afebrile eases : Four blood cultures were neg- 
ative. In 6 eases this method was not employed. 

Of the 25 febrile cases: Twelve cases were undoubted 
sepsis; 5 positive intrauterine cultures confirmed this; 
I negative intrauterine cultures failed to show this. 

In 3 cases blood cultures were not made. One case 
was typhoid fever; 1 positive intrauterine culture con- 
firmed this. 

Twelve cases were local infections (see above). Eleven 
negative intrauterine cultures confirmed this; 1 positive 
intrauterine culture was misleading. 

Of the 10 normal afebrile cases: Nine negative in- 
trauterine cultures confirmed this; 1 positive intra- 
uterine culture was misleading. 

Thirty-two intrauterine cultures were taken. The 
method failed to show septic infection in 4 out of 9 
septic cases. It showed apparent septic infection in 1 
out of 12 febrile cases in which general sepsis was 
absent. It showed apparent septic infection in 1 out of 
JO afebrile (normal) cases. 

On the other hand, 29 blood cultures were taken: 
Twelve showed the presence of Streptococcus pi/ogrnes, 
and these cases were clinically sepsis. One showed the 
presence of Bacillus ti/phosus and the autopsy confirmed 
this finding. Twelve (taken in febrile cases) were 
sterile and later developments in the cases showed suf- 
licient causes for the febrile condition. Four were 
sferile. These were taken in normal afebrile cases. 

In the series,' the l)lood culture did not fail in a single 
instance as a method of pT'ecision in diagnosis. The in- 
trauterine method, however, failed to show .sepsis in 4 out 
of 9 cases and, if the method has been relied upon, indi- 
cated septic infection in 2 cases which were pi'actically 
normal. 

Tlie influence that the bacteriologic e.xamination of a 
supposedly infected woman should have upon diagnosis 
and prognosis can be estimated in part by what has 
already been stated and must in part be judged by clin- 
ical experience. The findings by the examination of the 
lochia cannot be depended upon in making a diagnosis, 
and if treatment were uniformly governed by this exam- 
ination, mistakes of the grossest nature would often be 
made. For example, the procedure advocated by the late 
Dr. Pryor of opening the vaginal vault and packing the 
pelvic cavity with iodoform gauze in febrile cases in 
which streptococci were found in the uterus would often 
result in infecting an uninfected peritoneum, and in the 
comparatively few cases in which such an operation is 
really indicated, there might be no indication for it 
in the bacterial contents of the uterine cavity. 

Another question in this connection which must sug- 
gest itself is whether the presence of streptococci in the 
blood, indicating a general infection, contraindicates 
local surgical treatment and necessarily means a fatal 
issue if each flask of inoculated bouillon gives a very 
positive result in a luxuriant growth of streptococci. 
The answer to this question is best furnished by clinical 
experience. In one of the worst cases of general infec- 
tion the patient was saved by operative treatment (ab- 
dominal section and vaginal section with drainage). Of 
the 12 cases in whicli positive results were obtained three 
died of sepsis, one of an intercurrent pneumonia. The 



presence of streptococci in the blood, therefore, should 
not deter the operator from any surgical procedure 
which is obviously indicated and does not necessarily 
make the prognosis grave, though naturally the outlook is 
better if the infection remains localized than if it is 
general. 

The next question to be discussed is the routine in- 
strumental exploration and evacuation of the uterus in 
the treatment of sepsis after labor. I use these terms ad- 
visedly instead of that much misapplied expression curet- 
ment of the puerperal uterus. A long experience has 
taught me the necessity of this procedure in the majority 
of septic cases. There is usually a mass of hypertrophied 
and necrotic decidua in a septic uterxis the removal of 
which benefits the patient. No one can tell the condition 
of the uterine cavity until it is explored. Consequently I 
feel that the following procedure is essential in the treat- 
ment of the majority, if not of all, patients : The vulva 
and vagina are cleansed; a bivalve speculum (Collins) 
is inserted and widely distended; the cervjx is wiped off 
with pledgets of cotton and sublimate solution; an Em- 
met's curet forceps is gently inserted into the uterine 
cavity, cautiously opened and closed in all directions; if 
there is any doubt as to the removal of all the necrotic 
material, a broad dull curet is held between the thumb 
and forefinger and with the greatest gentleness is passed 
lightly over the uterine walls. If there is nothing in the 
uterus to be removed there is no result; if there is, it is 
discovered and removed at tiie same time, without trau- 
matism, without pain and without anestJiesia. This 
seems a much more sensible plan than to explore the 
puerperal uterus with the hand and then to evacuate it 
instrumentally if anything is discovered. The insertion 
of the whole hand in the uterus in the early puerperium 
will tear open wounds of tlie genital canal and is usually 
so painful to the patient as to demand an anesthetic. 
The gentle use of instruments is painless and is much 
quicker. 

The reason that instrumental exploration and evacua- 
tion of the puerperal uterus has fallen into disrepute is 
that the average physician has carried it out like curet- 
ment of the nonpuerperal uterus, a procedure neces- 
sarily often followed by fatal general infection or by 
perforation of the uterus. 

The use of antistreptococcic serum in the treatment 
of puerperal infection appealed strongly to every one, I 
think, who read the very convincing studies of Marmorek 
in the Pasteur Institute when they first appeared in the 
Annals of that institution. 7'he history of this treat- 
ment is fresh in the minds of most of us, I dare say. 
The Marmorek serum was used extensively all over the 
world with disappointing results; I employed it over a 
period of two years in some twenty odd cases without 
perceptible benefit. The American Gynecological Society 
appointed a committee which reported adversely on it, 
so that the majority of specialists in America, I think, 
dropped it. Lately a serum has been prepared in this 



130 American Medicine) 



AMEBIC DYSENTERY 



C JANUARY 27, 1906 
Vol. XI, No. 4 



country whicli can be secured fresh and which laboratory 
experiments at least have shown to be efficacious. Ac- 
cordingly I resumed the use of it this aixtumn. I have 
employed it in eight severe cases, five of which were not 
benefited in the least, three of which seemed to be mark- 
edly benefited, and in two of the latter the serum seemed 
to be immediately curative. Consequently I shall use it 
in cases in which the blood cultures give positive results. 
Large doses (80 cc.) should be given and the adminis- 
tration should be begun as early in the course of the dis- 
ease as possible. 

The vexed question of the operative treatment of puer- 
peral infection is a difficult one to deal with. There is 
no division of the subject on which there are more diver- 
gent views, at least in this country. I think an explana- 
tion of this fact is found in the anomalous relations to 
one another of the two branches of gynecology — obstetrics 
and diseases of women. The specialist in obstetrics has 
too often been deficient in surgical experience and abil- 
ity; the specialist in diseases of women has had no ex- 
perience with the varied phases of puerperal sepsis. 
Hence on the one hand operative treatment of puerperal 
infection is deprecated as unnecessary and unsuccessful, 
and on the other hand there is a disposition to advocate 
one specific operation as a cure-all. Pryor's operation is 
a good example of the latter tendency, so is hysterectomy 
early in the puerperium without some special indication 
for it, like suppurative metritis, necrosis of the myome- 
trium or infection of a uterine fibroid. So also is the 
proposition to excise the thrombotic veins in puerperal 
])hlebitis and to tie the ovarian vein in pyemia. As 
a matter of fact the most varied surgical procedures 
are demanded in a small minority of the cases 
of puerperal sepsis, for it is only in a minority of the 
cases that surgical intervention is indicated at all. In 
my own experience the following operations have been 
required : vaginal puncture for suppuration in the pelvic 
cavity ; salpingo-oophorectomy and excision of the broad 
ligaments with drainage for streptococcic or other patho- 
genic infection of the pelvic connective tissue and of the 
appendages; hysterectomy partial or complete, from ex- 
cision of the cornua to complete removal of the uterus 
for necrosis of the myometrium, suppurative metritis or 
infected fibroids; evacuation of intraabdominal ab- 
scesses by abdominal section varying from small isolated 
pus pockets between coils of intestines to general sup- 
purative peritonitis; vaginal and inguinal incisions to 
evacuate abscesses in the pelvic connective tissue; supra- 
pubic sections to evacuate an abscess in the connective 
tissue between the uterus and the bladder, not involving 
the peritoneal cavity; incisions into the pelvic joints to 
evacuate pus ; a lumbar incision for perirenal abscess ; 
incisions into the pelvis of the kidney for drainage; ab- 
dominal section for acute exacerbation of tuberculous 
peritonitis in the puerperium and for acute suppurative 
appendicitis; exploratory abdominal .sections in cases of 
suppurative cellulitis to be sure that there is no involve- 



ment of intraperitoneal structures and in intraperitoneal 
abscesses in wbicli it appears tbat the abscess can be 
more safely opened and drained by vaginal puncture. 
As may be seen, there is no single operation for puer- 
peral sepsis; tbcre is no one operation that may be said 
to take precedence over all others in frequency and u.se- 
fulness. The problems that have given me most con- 
cern in the operative treatment of puerperal infection 
are these : to determine when operative treatment, which 
ought to be avoided if possible, is really required, and 
to decide if vaginal, inguinal, lumbar, or suprapubic 
puncture will alone suffice without abdominal section. 
If it were possible to lay down dogmatic rules to gov- 
ern our action all difficulty would disappear. The recol- 
lection of certain principles, however, is usually helpful. 
The course of every case of infection should be carefully 
observed for the appearance of certain conditions whicli 
can only be relieved by surgical treatment. The operator 
should satisfy himself by physical signs of the presence 
of intrapelvic or intraabdominal inflammation and sup- 
puration before resorting to operative treatment of any 
kind. A careful bimanual examination, repeated under 
anesthesia if necessary, should indicate often if intra- 
peritoneal structures are free from involvement and if 
the infectious process is confined strictly to extraperi- 
toneal tissues, but there is so often justifiable doubt on 
this point that a preliminary exploratory section is usu- 
ally required to solve it. One point I think it is our 
duty to insist on most emphatically : that high tempera- 
ture, rapid pulse, high leukocyte count, and the pres- 
ence of pathogenic microorganisms in the uterus and in 
the blood are not of themselves indications for operative ., 
interference. 



INTESTINAL HEMORRHAGE AS A FATAL COM- 
PLICATION IN AMEBIC DYSENTERY, AND ITS 
ASSOCIATION WITH LIVER ABSCESS. 

BY 

RICHARD P. STRONG, M.D., 

Director Biological Laboratory, Manila, P. 1. 

(From the Government Biological Laboratory, Manila, P. 1.) 

Death may occur in amebic dysentery from the grav- 
ity of the intestinal lesions ; from exhaustion in pro- 
tracted cases ; from severe complications, particularly 
such as peritonitis due to the perforation of an ulcer in 
the large intestine or appendix, or an abscess of the liver 
or lung; from a terminal infection entering sometimes 
through the ulcerations in the large bowel ; from inter- 
current disease, and from severe intestinal hemorrhage. 
The last is of unusual occurrence and is a particularly 
rare fatal complication. 

While the presence of more or less blood in the 
stools in this variety of dysentery is, in fact, a common 
symptom of the disease, and while at times the dis- 
charges consist almost entirely of blood and mucus, it is 
obviously not to these conditions that I wish to refer in 
this paper ; instead, it is to the copious intestinal hemor- 
rhage, in which several hundred cubic centimeters of 



January 27, 1906T 
Vol. XI, No. 4 J 



AMEBIC DYSENTERY 



[Ambbican Medicine 131 



fresh blood are passed — such as one sometimes sees, for 
example, in typhoid fever and from which patients may 
succumb — that I wish here to invite attention. 

Upon reviewing the literature, I find that but little 
notice has been attracted to this complication. Of the 
recent textbook articles on the subject, Scheube,' in his 
description of gangrenous dysentery, states that occasion- 
ally large quantities of pure blood are passed, and even 
death may result from bleeding. Manson^ calls atten- 
tion to the fact that whenever in gangrenous dysentery 
sloughs separate, hemorrhage is always possible, and 
that sudden collapse may occur from this cause even in 
otherwise mild cases. Sodre' mentions that in some 
cases of acute and chronic dysentery an abundant hem- 
orrhage of the intestine may be observed. When it 
supervenes in an individual already weakened by former 
losses, or by many days of disease, death may result 
from it, the patient dying in collapse. None of these 
authors, however, refers particularly to hemorrhages in 
amebic dysentery. Kruse and Pasquale,* in their exten- 
sive monograph, do not mention .severe hemorrhage in 
amebic enteritis, and Harris,* in a summary of his own 
35 cases of the amebic variety and of 78 cases collected 
by him in the United States, also does not refer to this 
complication. Osier,* however, calls attention to it in 
acute amebic dysentery, and states that of the cases ad- 
mitted to his wards during the past 12 years, there were 
7 in which hemorrhage occurred from the bowels. The 
only direct reference I have been able to find in the 
literature of amebic dysentery in which the patient 
appeared to succumb from the loss of blood is one re- 
ported by Loffler.' In this case only 125 cc. of clotted 
blood was passed from the rectum. The author states 
that here a diphtheric inflammation of the intestine was 
added to the amebic infection. It was the only instance 
of this nature observed by LoflEler. 

The following cases of amebic dysentery are the only 
ones that have come under my notice in which the 
patients have succumbed to the hemorrhage. They, 
therefore, seem worthy of report : 

Case I. — Amebic dysentery ; fiver qbseestt ; severe mul- 
tiple intestinal hemorrhages ; death ; autopsy. 

The patient, a well-to-do merchant, aged 36, had 
resided in Manila for the pa.st two years. On February 
4, 1902, he consulted me, complaining of dysentery of 
several weeks' duration. An examination of the stools 
showed the disease to be of the amebic variety, the feces 
containing considerable blood and mucus and many 
actively motile amebas, some enclosing red blood cells. 
He was advised to enter the hospital for treatment, 
which he did. On admission, the subcutaneous fat was 
everywhere very abundant. The tongue was lightly 
coated and the conjunctivas of good color. The exam- 
ination of the heart and lungs revealed nothing abnor- 
mal. The spleen was not palpable and the liver not 
enlarged. The abdomen was not distended and there 
was no pain on pressure. The temperature registered 
99° and the pulse 72. Examination of the urine showed 
iiothing pathologic. The patient was placed upon liquid 
""iet and given Rochelle salt a half ounce. Local treat- 
inent consisting of high enemas of quinin solution 1-5000, 
was then begun and administered daily, the strength of 
the solution being gradually increased to 1-500, and the 
amount of fluid employed from one to two liters. 
Under such treatment and with occasional saline purges, 
he gradually improved. The tenesmus and irritability 






of the large bowel gradually decreased and the blood 
and mucus almost entirely disappeared from the feces, 
so that after three weeks' treatment the bowel move- 
ments became reduced to one or two per day, and the 
patient was up and about though still under treatment. 
The case seemed to be pro'gressing favorably. 

However, on February 25, the temperature, which 
had not been ^bove 99.5°, rose to 103° and the patient 
complained of headache and some pain in the chest. 
There was one bowel movement on this date. On Feb- 
ruary 26, the temperature remained in the neighborhood 
of 102°, but the patient complained of no pain. The 
bowels did not move for 24 hours. On the morning of 
February 27, a blood-examination of a fresh smear 
revealed some increase of the white blood cells and a 
blood count showed 25,000 leukocytes. He was given a 
half ounce of Rochelle salt, and an examination of the 
fluid stool passed shortly after revealed no blood. On 
microscopic examination a fair number of amebas and 
some epithelial cells and leukocytes were present. On 
February 28, the morning temperature registered 102°. 
The conjunctivas were slightly tinged with yellow. 
There was still complaint of some pain in the right side 
of the chest, but most of the pain was referred to the 
right inguinal region. The edge of the liver was not 
palpable. A blood count showed 28,000 leukocytes. A 
diagnosis of liver abscess was made and the patient was 
transferred to the surgical side of the hospital. The 
bowels moved but once on this date. On March I, the 
temperature ranged between 102° and 103°, and on 
March 2 it touched 104.2°. 

On March 3 he was operated upon. An incision was 
first made over the right hypochondriac region just 
below the costal margin and the lower portion of the 
right lobe of the liver exposed. An attempt was then 
made to locate the abscess through aspiration of the 
various portions of the liver with a long needle. This, 
however, failed and the liver was stitched to the abdom- 
inal wall and the patient returned to the ward. 

On March 2 and 3 there were no bowel movements, but 
on March 4 the bowels moved four times during the day. 
The stools were thin and yellow but only the first con- 
tained a little blood. On March 5 there were three 
bowel movements at night. These were yellow, formed, 
and contained no blood. It should be mentioned that 
the local treatment with enemas had been discontinued 
since February 26. The fever still continued. On 
March 6 there were six bowel movements of greenish 
yellow color, containing some milk curds and other 
undigested food. 

The patient was seen again by me on March 7. He 
then complained of pain in the region of the operation 
wound. While asleep there was considerable muttering 
and marked twitching of the hands. The temperature 
was 103.4°, the pulse 110. There was very slight jaun- 
dice of the conjunctivas. The abdomen was slightly 
distended. A blood count showed 18,000 leukocytes, 
there were three bowel movements on this date, one 
containing a little blood and mucus. A microscopic 
examination showed many amebas, some enclosing red 
blood cells. A diagnosis of typhoid fever was suggested 
by one of the staff in consultation and was particularly 
urged as the abscess had not been located, but arguing 
against such a diagnosis were the facts that the spleen 
was not palpable and there were no rose spots. More- 
over the serum failed in the afternoon of this day to give 
an agglutinative reaction with Bacillus ttyphosus. It was 
suggested that the local treatment witli quinin enemas 
be resumed and that another attempt be made to locate 
the ab.scess. Accord ingly aspiration was again performed 
by the surgical staff" through the abdominal wound, but 
still unsuccessfully. On March 8 there were two bowel 
movements after the enema of quinin solution, and on 
March 9, four. The movements were dark and thin, 
but macroscopically contained no blood. The tempera- 
ture ranged between 102° and 103.6°. 



132 



Amkbican MkdioinkI 



AMEBIC DYSENTERY 



rjANUARY 27, 190« 

LVOL. XI, No. 4 



On March 10, at 2.45 a.m., a large hemorrhage of 
about 500 fc. of fresh looking blood and containing four 
or five large clots was passed from the rectum. The 
pulse shortly after counted 140. The temperature was 
unfortunately not taken until two hours later when it 
registered 102.6°. The pulse then counted 134. The 
patient complained of great thirst, but apparently suf- 
fered no pain. On the morning of March 10, he was 
again seen. The subsultus of the hands was marked 
and there was some muttering delirium. The pulse was 
120, of high tension but not dicrotic. His condition at 
this time suggested typhoid fever, a diagnosis in fact 
adhered to by one of the hospital staff; yet upon a care- 
ful analysis of his symptoms, the diagnosis of typhoid 
hardly seemed justifiable, and the serum again gave no 
Widal reaction. At 11.30 a.m. of this day, a second 
intestinal hemorrhage occurred, about 300 cc. of dark 
blood being passed. On the following day the intestinal 
symptoms seemed a little improved, but the leukocyto- 
sis and fever continued. On March 12, at 8.30 p.m., 500 
cc. of fresh blood was passed from the rectum. The 
temperature dropped to 101° and the pulse became very 
weak and counted 140. An hour later another hemor- 
rhage of about 200 cc. occurred. At 6.30 p.m., a large 
amount of clotted blood was passed. The patient com- 
plained of great exhaustion and weakness. At 8 p.m. 
another large hemorrhage occurred and at midnight-and 
again at 12.30 a.m. smaller hemorrhages were passed. 
The pulse gradually weakened and increased in rapidity. 
Finally it no longer could be counted. The patient 
became very delirious and died during the night. 
Shortly before death there was a dark brown watery 
stool. 

At autopsy a large abscess measuring 12 cm. in diam- 
eter was found in the right lobe of the liver situated 
superiorly and near the posterior surface. The liver was 
not enlarged. The gallbladder and ducts were normal. 
The spleen also showed no pathologic change. The 
walls of the large intestine were not particularly thick- 
ened and there was no excessive edema of the submu- 
cous coat. In the ascending, transverse, and upper por- 
tion of the descending colon there were about 50 or 60 
ulcers scattered here and there, generally with even 
margins and with clean bases. Their edges were very 
slightly undermined. They measured from about 3 mm. 
to 12 mm. in diameter and about 1.5 mm. to 2 mm. in 
depth. Approximately 5 cm. below the cecum was an 
ulcer filled with a lightly adherent clot. On removal of 
the clot a freshly thrombosed vessel could be detected. At 
the edge of the ulcer the vessel was injected and could 
be traced with the naked eye for about 1 cc. in the sub- 
mucosa. There was no diphtheria in the large bowel. 
The mucous membrane between the ulcers was pale in 
color. The ulcers were clean and nothing in their 
appearance suggested a fatal issue for the disease other 
than the one containing the blood clot. The ileum 
appeared normal. There were no evidences of typhoid 
fever. 

The second case to which I wish to refer was seen in 
consultation with Dr. Otto Bartels, of Manila. 

Case II. — Amebic dyHentery ; liver abscess; multiple 
severe intestinal hemorrhages ; death; autopsy. 

The patient gave a history of having had several 
attacks of diarrhea during the past year, but had not 
noticed any blood in his stools. Since his entrance to 
the hospital a week before he had been complaining 
particularly of headache and restlessness. At times he 
had slight delirium. There was some constipation dur- 
ing this period. and purgatives and enemas were pre- 
scribed for him upon several occasions. Amebas were 
present in his stools. His temperature for four days 
previous to the time I first saw him, April 6, had varied 
between 99.4° to 102.6°. There was no distinct jaun- 
dice. Owing to the pain in the right hypochondriac 
region, to the fever and leukocytosis of 23,000, a diag- 



nosis of liver abscess was made and an operation advised. 
The patient, however, would not consent to an opera- 
tion. 

On April 8 there was a bowel movement, but none 
on the following day. On April 10, II, and 12 the 
bowels moved once each day. The stools contained 
some mucus, and on microscopic examination, in addi- 
tion to a few red blood cells, a number of motile amebas 
was observed. On April 11 hiccough appeared and 
persisted for several hours. At 5 p.m., April 13, a hem- 
orrhage occurred from the bowel of about 200 cc. of fresh 
blood. The pulse remained good, but the temperature 
fell from 101.5° to 98° two hours later. Early on the 
following morning the patient complained of pain in the 
abdomen and shortly afterward a large amount of fresh 
and partially clotted blood was expelled from the in- 
testine. Two hours later there occurred another hemor- 
rhage of about 400 cc. of bright red blood. The pulse 
became considerably weaker after the second hemor- 
rhage and the temperature fell nearly 4° in three hours. ■ 
The patient suffered from nausea and vomiting at inter- 9 
vals through the day and gradually became weaker. On " 
the following day the pulse became very feeble. The 
vomiting continued until within a few hours of his 
death, which occurred on the following morning. There 
were no more hemorrhages or bowel movements. 

At autopsy, there was a large abscess measuring 
about 14 cm. in diameter, situated in the right lobe of 
the liver. The left lobe contained a small abscess meas- 
uring about 7 cm. in diameter. The liver tissue was 
very fatty. The gallbladder and ducts were normal. 
The large intestine contained many shallow ulcerations, 
some of which were in the healing stage. The large 
bowel contained some dark clotted blood. After a care- 
ful search I was unable to locate any specific point from 
which the hemorrhage had occurred. Scrapings from 
the intestinal ulcers and from the walls of the abscess 
showed many motile amebas, some containing red blood 
cells. 

The question suggests itself why severe intestinal 
hemorrhage is not of more frequent occurrence in ame- 
bic dysentery, particularly when one considers the 
extensive lesions of the submucosa which are present in 
most of the advanced cases. However, the additional 
points in the pathology of the infection which would 
tend to prevent hemorrhage must be recalled, viz., the 
thrombosed condition of the bloodvessels in the zone 
of infiltration and edema which surrounds the ulcers, 
the infiltration of the walls of the arteries, and the 
more or less marked evidence of endarteritis, as the 
progress is rapid or slow. In chronic cases one may see 
at times the lumina of the arteries entirely occluded by 
this process. 

On the other hand, the frequent occurrence of smaller 
amounts of blood in the stools may be explained from 
the fact that the walls of the veins are early infiltrated 
with round cells, followed by softening and complete dis- 
organization ; also from the fact that amebas may pene- 
trate the walls of a vein ; however, thrombosis of the 
veins is not frequent. 

As a rule the blood in the stools in amebic dysentery 
probably arises not from one but from many ulcers about 
which the capillaries are usually considerably distended 
and frequently form a network at the bases and margins 
of healing ulcers. If at autopsy one removes the upper 
layer of the mucosa in the vicinity of an ulcer one fre- 
quently finds small hemorrhages in the upper portion of 
the submucosa. When the overlying mucosa becomes 
necrosed and sloughs, the blood from these vessels finds 



J^NU*«Y 27, 1906T 
Vol. XI, No. 4 J 



AMEBIC DYSENTERY 



[Ambrican Mbdicins 133 



its way into the lumen of the intestine and appears later 
in the stools. However, in the preceding cases, the 
hemorrhage probably arose from a single ulcer involving 
a bloodvessel. 

Since the foregoing observations were recorded to the 
Manila Medical Society in 1902, F. Haasler,' in the same 
year, in an article treating of the complications of ame- 
bic dysentery and reviewing 600 cases of the disease 
occurring in China, mentions three of severe intestinal 
bleeding, in two of which the hemorrhage was con- 
sidered the cause of death. In one of the cases about 
four liters of blood was passed and the author was able 
to tind at necropsy a thrombosed vessel from which the 
bleeding occurred. A most interesting fact in connection 
with these eases and one emphasized by this author is 
that in both of the fatal instances in which death was 
due to the hemorrhage, liver abscess coexisted. 

Woodward,' in 1879, also reported two cases of dys- 
entery in which profuse hemorrhage occurred and in 
which large liver abscesses also existed. In the first 
instance death resulted immediately from the hemor- 

' rhage. Though the cases were not diagnosed as those 
of amebic dysentery, there can be little doubt from the 

I histories and autopsies that they were indeed instances 

' of this variety of the disease. 

During the past two years I have encountered two 

, more fatal cases of amebic dysentery with severe multi- 
ple hemorrhages, in both of which large liver abscess 
was present. In the last one, the time of coagulation of 
the blood was not complete until nine minutes. There 

> was no marked jaundice present. 

These cases may here be briefly recorded : 

Case III. — Chronic amebic diysenterj/ ; multiple liver 
abscess ; severe intestinal hemorrhages ; death ; autopsy. 
^K The patient, aged 27, was first seen in October, 1903. 
^K this time his general physical condition was fair, but 
^K was already suffering with a well-advanced case of 
^Kiebic dysentery of about two months' duration. The 
^Kols were numerous and contained large amounts of 
mioodstained mucus. He was placed upon local treat- 
ment of high quinin enemas and pursued this treatment 
daily for nearly four months. During this time his gen- 
eral condition gradually improved. On several occa- 
sions for one or two weeics at a time, the stools became 
fairly normal, one or two per day, and contained no 
amebas and no mucus or blood ; but notwithstanding 
the fact that the local treatment was continued, the 
disease always broke out afresh and amebas and mucus 
and blood reappeared in the stools. In January, how- 
ever, he felt sufficiently improved to leave Manila 
for Japan, where he remained for about three months. 
During some of this time he neglected treatment en- 
tirely. For the first month he reported he was 
pretty well, but shortly afterward an acute exacerba- 
tion of the dysenteric symptoms appeared and he 
was compelled to enter a hospital. As soon as his 
condition temporarily improved he returned to 
Manila. He was seen again by me on April 9 ; at this 
time he was considerably emaciated and his face was 
drawn. He complained of an aching sensation in the? 
right shoulder. The liver was distinctly palpable for 
several fingers' breadth below the costal margin. The 
temperature registered 100° and there was a leukocytosis 
of 15,000. His pulse counted 112. The question of 
operation for liver abscess was considered, but was not 
immediately urged. Owing to the chronieity of the dys- 
entery and the general condition of the patient, it was 
decided that an attempt be first made to ameliorate the 



dysenteric symptoms. He was therefore placed again 
upon quinin enemas, with occasional doses of Dover's 
powder, and was given in addition stimulants, with the 
hope that in a few days his condition might so improve 
as to warrant an operation. His diet consisted only of 
liquids. The temperature ranged for the next two days 
between 100.2° and 103.2° The bowel movements num- 
bered three or four per day and usually contained consid- 
erable mucus. On April 12, at 9 a.m., his daily quinin 
enema was administered. During the day there were two 
bowel movements, the last at 3 p.m. At 7 p.m. a large in- 
testinal hemorrhage occurred, nearly a pint of fresh 
blood being passed. At 9 a.m. a second hemorrhage, 
smaller in amount but of the same character, occurred. 
At 12.30 a.m. a large amount of dark blood was passed. 
Morphin was administered hypodermically, and later 
ergot. Finally, a hot enema of tannic acid was given, 
but no favorable results were apparently obtained. Be- 
tween 12.30 and 8 o'clock the next morning there were 
five small hemorrhages. At the latter hour the tempera- 
ture registered 99° and the pulse 138. The patientgrad- 
ually sank. There were no more large hemorrhages from 
this time to his death, which occurred at 7 o'clock the fol- 
lowing morning, but the movements which occurred and 
were passed into a bedpan consisted almost entirely of 
clotted blood. 

At autopsy the large intestine showed extensive 
ulcerations throughout. The ulcers were, as a rule, 
shallow, usually undermined, and with smooth or 
slightly uneven reddened margins. In the cecum 
deeper ulcerations were present and between these lesions 
portions of the mucosa were covered with pseudomem- 
brane. Some of the ulcers in the cecum were gan- 
grenous. The contents of the large bowel consisted of 
dark reddish masses of fluid and partially clotted blood, 
together with some mucus. 

The lower end of the ileum for about 15 cm. above 
the valve also showed ulceration. No distinct point 
from which the hemorrhages arose could be detected 
anywhere in the entire intestine. 

There were six abscesses of the liver situated in both 
the right and left lobes and measuring from 5 cm. to 
10 cm. in diameter. A number of the hepatic veins 
contained thrombi. 

Case IV.— Amebic dysentery; liver abscess; severe 
intestinal hemorrhage ; death ; autopsy. 

The patient, a Spanish sailor, was first seen after an alco- 
holic debauch. At this time he was dull and stupid. He 
complained of acute dysentery. A companion stated that 
he had been bleeding extensively from the rectum during 
the previous day. At the time of my visit his temperature 
registered 99° and the pulse counted 114. No distinct his- 
tory of previous dysentery could be obtained. The 
patient refused to enter a hospital. A portion of a 
bowel movement, consisting of reddish-brown masses of 
blood and mucus, was secured, and a microscopic exam- 
ination showed numerous amebas and red blood cells 
and considerable altered blood pigment. Later in the 
day a blood count showed 9,000 leukocytes per cubic 
millimeter. The coagulability of the blood was tested and 
found to be complete only after nine minutes. The liver 
dulness was distinctly increased upward in the right 
axillary line above the fifth rib. The patient complained 
of slight pains below the right axillary region. The 
conjunctivas were slightly jaundiced. Morphin, calcium 
chlorid, and absolute rest were prescribed. The patient 
was seen again on the evening of the same day. At 
this time his pulse counted in the neighborhood of 150, 
and was weak and thready. The extremities were cold. 
He was already unconscious. His companion stated 
that he had passed three or four large hemorrhages from 
the bowels during the day. The sheet upon which he 
was lying partially disclosed this fact, being in places 
soaked with fresh blood. He gradually sank and died 
during the night. A complete autopsy could not be 
performed, but an incision was made over the right 



13 i American Mkdicine] 



TROPICAL LIVER ABSCESS 



rJANDABy 27, 1900 
LVOL. XI, No. i 



hypochondriac region, the liver drawn down, and the 
diagnosis of abscess in tlie right lobe confirmed. 

On recalling the infrequency of fatal hemorrhage in 
amebic dysentery, it seemed to me that some reason 
other than the anatomic situation of the ulcer might 
exist in the preceding cases, and which might account 
for the persistence of the bleeding and for their unfavor- 
able outcome. Since in all of these cases large liver 
abscess coexisted, the connection between intestinal 
hemorrhage and the hepatic condition has suggested 
itself very strongly to me. The idea that the destruc- 
tion of such large amounts of liver tissue may sometimes 
bring about serious functional disturbances of this organ 
and lead to a condition which predisposes to hemorrhage 
must certainly be considered. James Finlayson,'" as long 
ago as 1878, in discussing a case of liver abscess in which 
intestinal hemorrhage had occurred, argued that hepatic 
abscess by interfering mechanically with the portal cir- 
culation may produce congestion of the mucous mem- 
brane of the colon and thus favor the development of 
hemorrhage. The relation between hemorrhage and 
various other diseases of the liver, such as acute atrophy, 
syphilis, cancer, and affections of the biliary passages, 
particularly when jaundice is present, is well known. 
However, it is true that in typhoid fever severe and 
fatal intestinal hemorrhage may occur independently of 
any extensive lesion of the liver, though it has even 
been claimed that when such a result takes place it 
depends chiefly upon a diminished coagulability of the 
blood," or to special bacterial activity.'* Therefore, 
while it obviously is probable that more extensive ob- 
servations will show that fatal intestinal hemorrhage in 
amebic dysentery may occur entirely independently of 
liver abscess, the cases to which I have referred would 
seem to point out that at least when hemorrhage occurs 
in cases complicated with such hepatic disease it is likely 
to be very severe and that the bleeding is likely to recur. 

It is possible also that the occurrence of multiple 
intestinal hemorrhages in amebic dysentery may be 
occasionally of some importance in the diagnosis of liver 
abscess. In my last case there was no fever and no 
leukocytosis, and, although the liver was slightly en- 
larged and abscess was suspected, I did not feel by any 
means certain of such a diagnosis. However, when the 
intestinal hemorrhages appeared, reasoning from my 
knowledge of the conditions in the other cases, I felt 
confident of the existence of hepatic abscess, a diagnosis, 
which, as already mentioned, was confirmed at autopsy. 

In this connection I was recently much interested to 
find in Woodward's article on dysentery in the " Med- 
ical History of the War of the Rebellion, 1879," the 
statement that " hemorrhage from the bowels is another 
occasional symptom of liver abscess and sometimes is 
the immediate cause of death." This statement seems 
to have received no attention in the literature of amebic 
dysentery. 

We are about to undertake a study of the coagulability 
of the blood in our cases of amebic dysentery (employing 
Wright's method and that of Brodie and Russell, as used 
by Pratt) for the purpose of ascertaining if any changes 
occur either during the course of the uncomplicated disease 



or in those cases in which liver abscess or hemorrhage 
develops. 

BIBLIOGRAPHY. 

' Die Krankheiten der Warmen Liinder. 

•^ Manual ofTropical Diseases. 

'Twentieth Century Practice of Medicine, Vol. xvi. 

* Zeitsch. fiir Hygiene, 1894. 

* American Journal Medical Sciences, 1898. 
' Practice of Medicine. 

' AUbutt's System of Medicine, Vol. ii. 
' Deut. med. Wochenschr. 

9 Medical and Surgical History of War of the Rebellion, II. 
Med. Vol., pp. 164 and 209. 

"Glasgow Medical Journal, February. 1873, p. 171. 

11 Wright and Knapp : The Lancet, 1902, Vol. ii, p. 16, I'Ai. 

"Nicholls and Learmonth: Ibid., 1901, Vol. i, p. 305. 



TROPldAL LIVER ABSCESS: REPORT OF THREE 
CASES, WITH SPECIAL REFERENCE TO THE 
BLOOD FINDINGS. 

BY 

J. MORGAN COFFIN, M.D., 
First Lieutenant, Assistant Surgeon, United States Army. 

During the period beginning January 1, 1902, and 
ending August 31, 1905, 10,603 cases in all were treated 
in the wards of the United States Army Division Hos- 
pital, at Manila, P. I. Of this number, 1,523 were of 
the dysenteric type, classified as follows : amebic, 859 
(diagnosis confirmed microscopically) ; catarrhal, 236 ; 
and dysentery, acute or chronic (type not noted), 428. 

Members of the military forces of the Philippine 
Division are treated in the hospital of the post at which 
they are serving, and the cases which respond to treat- 
ment are cured and the men returned to duty. The 
division hospital receives dysenteries whom it is 
thought necessary to transfer to the United States. 

Therefore, of the 1,523 cases mentioned, the vast 
majority, particularly those of the amebic type, were 
more or less of an intractable character, and the patients 
were invalided home after an extremely short period of 
observation, varying from one to eight weeks. It is for 
this latter reason that the condition of amebic or tropic 
liver abscess, to whicli I wish to call attention, is so 
comparatively rarely recorded, there being only 34 cases 
noted during this 3f-year period. Of these I wish to 
report in detail three, occurring in my personal service, 
and with the remainder, none of which have been pre- 
viously reported, endeavor to draw a few conclusions, 
particularly in regard to the leukocyte count found in 
this most interesting condition. 

Case I. — W. L. D., male, white, aged 28, admitted 
May 15, 1905. Civilian, Q. M. employe. Born in New 
York. 

Family History. — Father died of gastroenteritis. 
Mother, one brother, and three sisters living and well. 

Previous Personal History. — He has been in the Phil- 
ippine Islands four years. He has never had pneu- 
monia, pleurisy, typhoid, or malarial fever. He had 
dengue fever and rheumatism in 1902 ; dysentery in 
August, 1904, and was in the hospital two months. He 
had a severe pain in the right side and diarrhea at that 
time. The laboratory reports during that period show : 

August 17, leukocytosis, faint trace of albumin in the 
urine, no casts; August 21, leukocytosis 21,800, malaria 
negative, stools contain ameba coli ; August 22, leukocy- 
tosis 21,800 ; August 23, leukocytosis 23,400, negative 
malaria and Widal ; August 25, leukocytosis 26,800, 



January 27, I906T 
Vol,. XI, No. 4 J 



TROPICAL LIVER ABSCESS 



[AHEKIOAN MeDIOINB 135 



later 35,200; August 26, leukocytosis 36,700, i. e., poly- 
morphonuclear neutrophiles 70.3%, eosinophiles* 2.3/^, 
transit 10^ , small mononuclears 7 ft> , large mononuclears 
iOfc, malaria negative ; August 27, leukocytosis 38,500 ; 
August 29, leukocytosis 49,500 ; August 30, leukocytosis 
30,800, later 22,460 ; September 4, leukocytosis 15,600 ; 
September 11, leukocytosis 8,800 ; September 23, leuko- 
cytosis 16,200. 

The patient was discharged October 10, 1904, with a 
diagnosis of chronic amebic dysentery. No positive 
diagnosis of liver abscess was made at that time. 

Present Attack. — The patient has practically never 
been well since leaving the hospital. Cramps and abdom- 
inal distress occur after eating. Pain in the right 
hypochondrium began a month ago, gradually becom- 
ing worse, on occasions referred to the right shoulder. 
He has never had jaundice. There has been no nausea 
or vomiting and no diarrhea since leaving the hospital 
in October. 

On Admission. — Pain and tenderness are present in 
the right hypochondrium. No nausea or vomiting. 
Appetite is fair. Bowels are constipated. There is no 
cough, no vertigo, no dyspnea, no headache. Loss of 
weight 15 pounds. He is quite weak. The lungs are 
clear throughout. 

Heart. — Third interspace, left parasternal line. Apex 
beat in fifth interspace in the midclavicular line. The 
sounds are clear and of good quality. 

Zwer.— Midaxillary line, sixth interspace ; midclav- 
icular line, fifth rib ; posteriorlj', tenth interspace. 

The lower edge is not palpable on account of tender- 
ness, but appears to extend 1 cm. below the costal 
border. Percussion over the entire area of hepatic dul- 
ness gives rise to acute pain. There is no jaundice. 

Spleen. — Not enlarged. 

May 16, leukocytes 13,600, feces negative for ameba, 
urine negative, fever irregular, varying from 100° to 
104° ; May 17, condition of the liver unchanged, no 
Jaundice ; May 18, blood count, red blood cells 4,320,000, 
leukocytes 16,600, hemoglobin 85%; May 19, tenderness 
disappearing over the sixth and seventh ribs, but per- 
sistent below ; patient transferred to surgical ward with 
iHagnosis of abscess liver, amebic. 

May 25, the patient was operated upon by Lieu- 
tenant W. H. Moncrief. An incison was made 1 cm. 
below and parallel to the costal border, in the right 
upper abdominal quadrant. On exposure and palpation 
of the liver there was no evidence of fluctuation. Pus 
was located by aspiration. Incision revealed an abscess 
cavity the size of a walnut in the right lobe, 5 cm. from 
the surface. Drainage was instituted. 

May 26, slight discharge with little odor ; May 28, 
Improving, all packing removed ; June 7, improvement 
continued until two days ago, when the patient's appe- 
tite became capricious and he complained of general 
malaise, with elevation of temperature. Some pain 
about the wound, very severe la.st night. Examina- 
tion of dressings showed profuse purulent discharge. 
He was anesthetized, and a large abscess cavity demon- 
strated above and to the right of the smaller one first 
found ; 250 cc. to 300 cc. of pus was evacuated ; June 9, 
discharge is decreasing; June 20, pus from abscess cav- 
ities negative for ameba ; July 10, healing complete, 
patient discharged as cured; August II, blood count, 
four months after operation, red blood cells 4,670,000, 
leukocytes 5,200, hemoglobin 92%. 

Cask II. — Y. H. S., male, white, aged 27; private 
Troop B, Second Cavalry; admitted September 9, 1905. 

Fomilji Ilistori/. — Unimportant. 

Previous Persona/ HMorj/. — Measles and mumps in 

*In an interesting paper read before tlie Patliological 
Society of Philadelphia, December 25, 1905, H. M. Snyder called 
attention to the work iieiiiK done npon eosinophilia in amebic 
dysentery and reported a case. Further investigation in re- 
gard to eosinophilia in amebic liver abscess should prove in- 
teresting. 



childhood. He has never had pneumonia, typhoid, or 
rheumatism. No gastric or intestinal symptoms previous 
to his arrival in the Philippine Islands a year and ten 
months ago. June, 1904, he was sick in the hospital for 
ten days with fever, for which quinin was tiiken. He 
was cured. 

December, 1904, he had dysentery, with blood and 
mucus in the stools ; this continued for three weeks and 
was apparently cured. It has never recurred since, in 
fact, he states that a condition of chronic constipation has 
supervened. In May, 1905, patient states that he vom- 
ited a round worm. 

History Previous to Admission. — While shoveling 
sand on fatigue at post, June 10, 1905, patient states that 
he slipped and was seized with an acute pain in the 
lower right chest. That night he noticed that he could 
not lie on his left side on account of the pain ; also 
noticed the presence of some dyspnea. The day follow- 
ing he was admitted to the post hospital. About five 
days later he noticed a peculiar "trickling" sensation 
in the right side. Fairly well from then until the begin- 
ning of September, when he had fever and sweats. Two 
distinct chills. 

Condition on Admission, — Some soreness in the epi- 
gastrium, with slight pain in the right shoulder. No 
cough ; no dyspnea ; no expectoration ; no pain in chest ; 
no vertigo; no headache; no appetite; bowels regular. 
He complains of being very weak and sleeping poorly, 
but aside from this says that he feels well. Physical 
examination shows flatness over the lower lobe of the 
right lung as high as the sixth rib in front and the eighth 
rib posteriorly ; absence of breath sounds over this area ; 
absence of resonance and fremitus. No change in dull 
area in changing position. Bronchial breathing over the 
remainder of the right lung. The left side of the chest 
is negative. The heart is not enlarged and the sounds 
are clear and of good quality. The liver dulness merges 
with that mentioned and extends downward to the 
costal border. The spleen is not enlarged. Remainder 
of the abdomen is negative for tenderness and masses. 
No jaundice. Fever irregular, 99° to 102°. 

He was transferred to the surgical ward September 
12, 1905, with diagnosis empyema, right pleural cavity, 
cause probably pleurisy with eff"usion. 

September 13, right side of chest aspirated and 400 cc. 
of reddish-brown purulent fluid drawn off. Microscopic 
examination determines nothing definite as to the char- 
acter of the fluid. 

September 15, operation was performed by Lieutenant 
W. H. Moncrief. Thoracotomy ; evacuation of ap- 
proximately 1,000 cc. of pus after excision of 6 cm. of 
the eighth rib. Pus very thick and creamy, largely 
tinged with red. Very unlike usual fluid seen in cases 
of empyema. The walls of the chest cavity over the 
lower two-thirds are covered with thick grumous 
material ; this was loosened up and evacuated. Careful 
exploration failed to demonstrate conclusively to touch 
any opening in the diaphragm ; but the incision was not 
enlarged nor special efforts other than digital examina- 
tion used to determine this. A large rubber drainage- 
tube inserted. 

October 31, uneventful convalescence. Tube grad- 
ually shortened and wound healing, until this day the 
process is complete. 

lAibornlonj iJepor^s.— September 9, blood for malaria 
negative. September 10, blood for malta fever negative ; 
reaction 1 to 100, two hours ; urine contains a faint trace 
of albumin. September 12, blood for malta fever nega- 
tive ; reaction 1 to 40, one hour ; malaria negative ; 
leukocytes, 12,800. September 16, urine contains a faint 
trace of albumin. September 17, urine negative; stools 
negative for ameba. September 19, stools negative for 
ameba. September 20, pus, thoracic cavity contains pus 
and red blood cells and actively motile ameba. 

November 14 he started for the United States, 
cured. 



136 A.HKBIOAII MEDIOINS] 



TROPICAL LIVER ABSCESS 



rjANUARY 27, IBOli 
LVOL. XI, No. 4 



Case III.— W. A., male, aged 30 ; civilian employe, 
Q. M. D. ; American negro ; admitted June 28, 1905 ; 
diagnosis undetermined. 

Family i/i.s)!or/y.— Unimportant. 
Previous Personal History.— He has been in the 
Philippine Islands six years. Previous to his arrival he 
had always been healthy and well. He had malarial 
fever in 1900. He has had four attacks of dysentery 
with blood and mucus in the stools; the last attack 
occurring in 1902. On April 29, 1905, without any 
known exciting cause, the patient states that he began 
to have pain and tenderness, or rather "soreness," in 
the right hypochondrium, with fever, but no vomiting 
and no diarrhea. He was operated upon May 3, in a 
civil hospital, for " an abscess in the side." 

Present Co/?rft7io».— Complains principally of a dull 
ache in the right hypochondrium just below the margin 
of the ribs ; not referred. Feels feverish, with occasional 
sensations of chilliness, but no distinct rigors. No cough, 
no pain in thorax, no dyspnea, but he states that deep 
inspiration causes a stitch in the side. Belching and 
flatulence are present, but no nausea and no vomiting. 
Bowels are constipated. 

The patient looks apathetic. He lies on his right 
side with his right thigh flexed. The mucous mem- 
branes have a very slight yellowish tinge. The tongue 
is fissured, dry, and furred. The lungs are clear through- 
out ; no rales, no dulness, and no friction sounds at the 
right base. 

//(.f„-^_Lower border of the third rib; left paraster- 
nal line to apex beat, which is visible and palpable in 
the fifth interspace, midclavicular line. The heart sounds 
are clear and of good quality. 

Abdomen shows a scar in the right upper quadrant 
5 cm. long and 1 cm. below the costal border. 

The liver dulness is defined a-s follows : The upper 
border corresponds to the flflh rib in the midclavicular 
line and to the sixth in the midaxillary ; from here it 
extends downward to 3 cm. below the costal border. The 
edge feels firm to the touch and is extremely tender to 
palpation. The spleen extends from the ninth to the 
eleventh rib and is not palpable. His weight is 135 
pounds. 

The urine contains a trace of albumin, but no casts, 
specific gravity 1,015. The stools are negative for ameba, 
but contain trichomonas. The leukocyte count is 12,000. 
He was transferred to the surgical ward July 8, 1905, 
with a diagnosis of abscess liver, amebic. 

July 5, complains of severe pain in the right side, but 
no change in the physical signs, fever of varying intensity, 
99° to 102.6° ; July 6-10, is fairly comfortable, but condi- 
tion is not improving, the leukocytosis persisting and the 
local condition of the liver remaining unchanged. It is 
decided to operate. July 11, operation performed by 
Lieutenant R. F. Metcalfe ; a .subcostal incision was 
made and an abscess cavity of 4 em. in diameter found 
by aspiration near the surface of the right lobe; it was 
incised and drained ; August 18, despite operation, the 
patient continues to lose flesh and strength, his appear- 
ance is septic, albuminuria continues; determined in 
consultation that a second collection of pus exists and 
reoperation decided upon ; August 19, operation, 3.5 cm. 
of the eighth rib was excised in the midaxillary line, 
the liver was reached and a cavity approximately 2.5 cm. 
in diameter incised and drained. 

Following this operation the pain continued, the area 
of hepatic dulness remained unchanged, there was pro- 
gressive loss of flesh and strength, and jaundice. Diar- 
rhea set in ; the stools contained mucus and were 
extremely fetid. The patient became septicemic and 
died September 9, 1905. 

During the time in which he was an inmate of the 
hospital there was no evidence of cardiac or pulmonary 
involvement or of a general inflammatory process in the 
peritoneum. 



I,ABORAT()RY REPORT. 

Blood : Leukocytes, June 29, 12,000 ; July 1, 11,600 ; 
July 6, 11,800; July 17, 12,400; August 3, 9,000 ; August 
13, 12,000. 

Urine : June 27, specific gravity 1,015, trace of albu- 
min, no casts; July 11, specific gravity 1,007, trace of 
albumin, no caste; July 12, specific gravity 1,022, faint 
trace of albumin, no casts; August 13, specific gravity 
1,007, faint trace of albumin, no casts; August 20, spe- 
cific gravity 1,018, no albumin, no ca.sts. 

Pus from wound : July 11, negative for ameba. 
Feces : Despite repeated examination, amebas were 
not found in the stools until September 2, from which 
time on they were present with pus cells and a few eryth- 
rocytes. 

Autopsy.— ^\x hours after death. Body is that of a 
somewhat emaciated colored man of middle age. Rigor 
mortis is present in muscles of lower extremities and 
neck, but absent in upper extremities. Pupils equal and 
moderately dilated. No general glandular enlargement. 
Thorax : Pleural cavities free of adhesions and exu- 
date. Lungs moderately inflated, pale salmon-pink on 
section ; no nodules. 

Heart of normal size, pericardium contains 50 cc. of : 
straw-colored fluid, endocardium free of vegetations, 
yellow-white clots in both sides of the heart. 

Abdomen : In para.sternal line there is an old scar 
just below the costal border 5 cm. long. In the mid- 
axillary line there is a wound 7.5 cm. long through the 
skin and leading down to the liver, covered with a thick 
plastic exudate. Both of these are just beneath the cos- 
tal border. Over the eighth rib in the anterior axillary 
line there is a wound 10 cm. long, through which a rub- 
ber tube protrudes; 4 cm. of the eighth rib have been 
resected. On slight pressure a yellowish-brown semi- 
fluid exudate appears in the wound. 

On opening the abdomen the liver is found to be 
adherent to the diaphragm, and the pleura through 
which the operating wound was made has so adhered as 
to shut off" the pleural cavity, so that the drainage- tul:)e 
before mentioned appears to lead directly into the liver 
and is without connection with either the pleural or 
abdominal cavities. 

At this point in the liver corresponding to the para- 
sternal line there is a small, short sinus surrounded by 
scar tissue. 

On the under surface of the right lobe there are many 
adhesions binding the right kidney and adrenal, together 
with the hepatic flexure of the colon, to the under sur- 
face of the liver. The kidney and adrenal are with diffi- 
culty dissected free and are found to be uninvolved. The 
colon, however, contains a 1 cm. opening into an abscess 
cavity in the liver. This cavity is approximately 
12 cm. by 10 cm. by 10 cm. and is lined with firm tissue, 
which internally is black, and of a slightly glistening 
white color where it is connected with the surrounding 
liver tissue. The cavity is partially filled with yel- 
lowish-brown semifluid pus. Lying above this abscess is 
another, which is just at the dome of the liver; it is 
smaller in size and filled with a yellowish-white thick 
material. Its wall is white, thick, and fibrous, and 
forms part of the wall of the abscess beneath. The kid- 
neys, adrenals, bladder, and pancreas present no note- 
worthy features. The spleen is adherent to the dia- 
phragm, is of a light red color, soft, not enlarged, 
trabeculas distinct. The stomach and small intestines 
are apparently normal. Beginning with the caput coli, 
and extending to the rectum, the large intestines are 
found to be the seat of ulcerations. These vary in size 
from a pinhead to a centimeter, are scattered through 
the width of the gut, and are at times undermined with 
swollen borders. These ulcers rarely extend to the 
muscular coats, except at the hepatic flexure, near which 
they appear deeper. The mucous membrane remaining 
is injected and in certain areas superficially necrotic. 



January 27. 19061 
Vol. XI, No. 4 J 



TROPICAL LIVER ABSCESS 



[American Mkoicin* 137 



Microscopic examination of tlie discharge from the 
wound, the contents of the abscesses, the walls of the 
intestinal ulcers, and the feces, all show living amebas. 

Anatomic Biaffnos is. —Amebic dysentery and abscess 
of the liver, chronic, adhesive, and localized pleuritis 
and peritonitis. 

Manson,' with his wide experience in tropic diseases, 
has most truly written that " golden rules in tropic prac- 
tice are to think of hepatic abscess in all cases of progres- 
sive deterioration of health, and to suspect liver abscess 
in all obscure abdominal cases associated with evening 
rise of temperature." 

In the light of the preceding, I feel that a repetition 
of what are probably wellknown facta in regard to hep- 
atic abscess, with the little additional information which 
may be gleaned from the foregoing cases, will not be 
amiss. 

History. — Hepatic abscess has been known since the 
time of Hippocrates, who described cases of the disease, 
together with the opening of the abscess cavity by 
cautery. It may be interesting to us to know that 
Osier ^ was the first American physician to report this 
condition, demonstrating ameba coli in the contents of 
the abscess. 

Etiology. — In speaking of the ameba found in connec- 
tion with liver abscess, the ameba coli described by 
Losch is referred to. This name was given by him to a 
pathogenic ameba, and as Wooley and Musgrave ' state, 
" why this term should be applied to a suppositious 
nonpathogenic organism it is difficult to say." 

Predisposing Causes. — Climate : It is practically cer- 
tain that climate plays an important role, if only from 
the fact that a change of residence from a temperate to 
a tropic zone leads to hyperemia of the liver, rendering 
it more susceptible to the action of the exciting cause. 

Season is not a factor. Rogers,* in an analysis of 236 
cases, concludes that the seasonal influence is nil. My 
cases are entirely too few in number to enable me to 
draw comparisons ; with the exception of a slight dimi- 
nution in the number occurring in the third quarter, 
there is no variation. 

Race : The native race of a given country enjoy a 
comparative immunity, even though the percentage of 
dysentery may be much higher among them ; this is 
well illustrated by the following table given by Manson ' 
for the year 1894 : 

Dysentery, admission per 1,000 strength: Native 
army of India, 43.8 ; European army of India, 28.6. 

Liver Abscess: Proportion deaths to total mortal- 
ity : Native army of India, 0.6 ; European army of 
India, 7.4. 

The immunity of the native races diminishes in pro- 
portion as they approach more nearly the standard of 
living set by the Europeans with whom they are in con- 
I tact, and as they come under the influences of urban life. 

Exposure by aflfecting changes in the blood supply of 
the liver becomes of etiologic significance. 

Sex : The disease rarely afffects the female ; and this, 

' independent of the fact that almost all the men who 

' have worked on this hepatic condition have based their 

statistics upon practice among soldiers or government 

employes where necessarily the males predominate. 



Age : The period from 20 to 40 appears to be that 
in which the vast majority of cases are noted. It is 
said by some auftiorities not to occur in childhood, but 
Arnott* reports a case in a child of 2J years, and Am- 
berg " has placed on record five cases. Old age, again, 
enjoys comparative immunity. 

Alcohol and improper food, by diminishing the re- 
sistance of the liver, increase the frequency of abscess 
formation. Rogers' finds a history of alcohol in over 
50 /c of all cases. 

Disease : Yellow fever, by bringing about degener- 
ate changes in the liver, is said to leave in its train a 
field for the development of liver abscess. 

Cirrhosis of the liver has no etiologic significance. 

Malaria : One who has been, even for a short time, 
in the tropics, and has observed at autopsy the changes 
taking place in the liver, particularly in the estivo- 
autumnal type of this disease, must grant that it plays a 
part, not as a determining, but as a predisposing factor 
in hepatic abscess. When we consider, however, the 
few cases in which hyperplasia of the spleen is associated 
with liver abscess, the infrequency of even this must be 
granted. Malbot,' however, concludes that malaria is 
the most eflfective predisposing cause, and that dysen- 
teric factor is less active ; the role of the latter being that 
of any other intestinal lesion, in carrying the seed to the 
ground already prepared by malaria. 

Dysentery : The question as to whether this disease 
shall be considered a predisposing or exciting cause de- 
pends on the light in which we regard hepatic abscess ; 
as per se, a complication of amebic dysentery, or as a 
separate and entirely distinct manifestation of the path- 
ogenicity of the ameba coli ; in other words, as hepatic 
amebiasis. I am inclined to the latter view. That a 
certain definite percentage of cases have neither a his- 
tory of dysentery nor lesions at autopsy, but present 
ameba in the abscess contents, confirms this theory. 

Rogers* gives the following table from an analysis of 
39 cases : 

Cases. ii 
Previous history, dysentery and lesions at autopsy ..21 
No " " " but " " .. 7 

41 II .1 " jjo " " .. 6 

No " " " and •• " " , ..5 12-83 

A summary of my cases shows recoveries, with a 
previous history of dysentery, 15 cases ; no previous 
history of dysentery noted, 3 cases ; deaths, with a pre- 
vious history of dysentery, lesions at autopsy, 7 cases ; 
no previous history of dysentery, lesions at autopsy, 2 
cases ; no previous history of dysentery, no lesions at 
autopsy, 2 cases. No autopsy in 5 cases ; 3 have had 
ameba in stools and history of dysentery. 

Kelsh and Niemier,* in an analysis of 500 observa- 
tions, find that in 8b fo dysentery is found associated 
with liver abscess. 

Malbot,' in his 19 cases, found that only six patients 
had dysentery before or after, but grants that dysentery 
may be the pathogenic cause, though proof of it is 
lacking. 

Kartulls' believes that a small number may be 
ascribed to other causes, and apparently have no connec- 
tion with amebic dy.sentery. 

Rolleston '» cites a case in which the typhoid bacillus 
was the cause of a large single abscess. 



iMel^'-^isT.is 

15.38 ) 



138 Amkbican Mkdicink) 



TROPICAL LIVER ABSCESS 



C.UnuaBY 27, I90ft 
Vol. XI, No. 4 



Buchanan" quotes a large number of cases for his 
contention that dysentery is not at all an important 
factor in the occurrence of liver abscess. He points out 
the frequent occurrence of dysentery among the natives 
of India, and at the same time calls attention to the few 
cases of liver abscess. The decrease in liver abscess 
among the white soldiers was synchronous with increase 
in abstinence ; so that beside dysentery, still another 
important factor must be present to account for liver 
abscess. 

To me it appears that the rational theory is that the 
role which the active dysenteric process plays is that of 
rendering more facile the passage of the ameba coli from 
the colon to the liver, opening by its tissue destruction 
and ulcer formation three routes of hepatic infection, 
where but one, the common bile duct, exists in health. 

Exciting Cause». — Ameba Coli : The scope of this 
article does not allow of a discussion of the biologic, cul- 
tural, and etiologic significance of this protozoon, aside 
from its relation to liver abscess, and the reader is 
referred to the special articles bearing on this subject. 
Nor will Bacillus dysenteric be considered. 

The ameba coli is the only organism constantly found 
associated with tropic liver abscess, the pyogenic bac- 
teria being absent in the majority of cases when the 
abscess is first opened. Kruse and Pasqual '^ found all 
varieties of bacteria, but no specific element aside from 
ameba, and are firmly determined that amebas are the 
primary agents, but that they always occur in company 
with bacteria which are not specific but possess path- 
ogenic properties. 

Assuming the presence of ameba coli in the intestine, 
either normal or dysenteric, there are three routes 
through which it may gain access to the liver: (1) 
Through the portal vein ; (2) by an outwandering from 
the gut across the peritoneum ; (3) via the common bile 
duct. These will be taken up seriatim. 

1 . Through the Portal Vein : This method of hepatic 
infection is, in all probability, by far the most common. 
WooUey and Musgrave ' have in a recent article demon- 
strated ameba in the bloodvessels of the mucosa and in 
the dilated veins of the submucosa, thus rendering their 
transmission to the liver by way of the portal system a 
simple mechanical flow. 

2. Across the Peritoneum by Ameboid Movement: 
Dopter," quoting Jiirgens,'* states that the latter has 
observed amebas as deep as the peritoneal serous coat in 
cats, which were the subject of experimental dysentery, 
and in view of the ease with which the ameba penetrates 
tissue, it becomes clear that their outwandering from the 
gut and subsequent migration across tlie peritoneum to 
the liver are feasible. Rogers'^ believes that this is the 
most common method of infection, in this way account- 
ing for the preponderance of the single over the multiple 
type of abscess. Bassett-Smith's'" case of infection of 
the lung without perforation of the diaphragm well illus- 
trates the power of the organism to infect without solu- 
tion of the continuity of tissue. 

3. Through the common bile duct, this constituting 
a direct route for the passage of protozoa, by their ame- 
boid movement, to the liver. The failure of observers 
thus far to demonstrate ameba in the lymph-glands 



precludes, for the present at least, the inclusion of a 
fourth route of infection, i. e., through the lymphatics. 
The situation of the dysenteric ulcers in the intestine has 
some bearing on the frequency of infection of the liver, 
ulcers of the caput coli and ascending colon being more 
apt to be associated with disease of the liver than corre- 
sponding disease lower down in the gut. In fact, Kar- 
tulis ' advocates early extirpation of the appendix if its 
involvement, during the course of dysentery, is, sus- 
pected, believing that this will do away with many of 
the socaJled cases of idiopathic liver abscess. 

Pathology and Morbid Anatomy. — Dopter," working 
on the pathology of dysentery, has demonstrated that 
when the ameba penetrates a tissue it determines both a 
local action and an inflammatory reaction at a distance. 
This is soon followed by necrosis, a constant and essen- 
tial manifestation of its pathogenic action. The ameba 
having gained access to the liver and lodging in one of 
the portal radicles, a clot follows. The blood supply is 
shut off". A focal necrosis ensues, the amebas proliferate, 
and then ensue the changes mentioned. If the infection 
is by either of the other routes the pathologic process as 
described by Dopter ensues immediately. 

Assuming that the amebas gain access to the liver by 
any of the three routes, abscess formation in the light 
of the preceding is easily explained. The growth in 
size of the cavity and its development are further stages 
in the process of proliferation of the protozoa and 
necrosis of the liver cells. That it is not true inflamma- 
tory process is shown by the fact that the characteristic 
inwandering of the leukocytes is absent. 

The Abscess. — Statistics show no immune region of 
the liver. Approximately 70^ of all abscesses are 
located in the right lobe, the remainder in the left. 
Less than 1^ are found in the lobus speigelius. The 
most common site is the convexity of the right lobe, 
near the surface. Singleness is the rule and Cases I and 
III are exceptional in their multiple feature. 

There is no evidence of acute inflammation about the 
abscess cavity"; in the majority of cases the formation 
resembles more nearly the tuberculous " cold abscess " 
than a pyemic process, and the wall is composed of 
necrotic and broken-down liver tissue. In a few cases a 
slight inflammatory process supervenes and forms a wail 
of fibrous tissue. 

The contents of the abscess may be "laudable " but 
more often consist of chocolate (Anchovy sauce) colored 
pus ; this being composed of detritus from the broken- 
down liver cells, pus cells, ameba coli, motile or dead, 
and occasionally bacteria, though in the majority of 
instances the contents are sterile when the abscess is first 
opened. As to the presence or absence of the amebai 
Rogers " finds the living ameba during life or at autopsy 
in two-thirds of the cases which are otherwise sterile. 

During life the amebas as a general rule do not 
inhabit the pus itself but are found on and in the 
walls of the cavity, thus accounting for their occasional 
absence immediately succeeding operation and their 
subsequent appearance in the wound discharge; and 
similarly postmortem scraping of the wall may reveal 
their presence when examination of the pus was negative. 

Clinical Picture. — The period of latency varies greatly 






January 27, 19C6T 
Vol. XI, ISO. 4 J 



TROPICAL LIVER ABSCESS 



[Amkkicax Medicinb 139 



from weeks to even years, but the three cases reported 
illustrate the usual development. Pel'* reports three 
cases in which, respectively, tropic dysentery had oc- 
curred 11, 15, and 21 years previously. 

The onset is usually indefinite and presents no path- 
ognomonic signs ; usually at varying intervals, after an 
attack of amebic dysentery, the following symptom-com- 
plex presents itself: The fever is not distinctive, but 
usually assumes hectic characteristics. It may be entirely 
absent ; Keble '» reports such a case. In all of the 34 
cases in my series fever was present. The pulse varies 
with the temperature. As a rule, distinct rigors are 
absent, though the patient complains of chilliness. 
Sweating is usually quite profuse. The pain is of a dull, 
aching character, located in the right hypochondrium, 
and not distinctive of the condition of abscess, though 
Malbot' insists on its diagnostic importance. In 50 % of 
the cases it is referred to the right shoulder. Cough, 
either reflex or from secondary involvement of the lung 
or pleura, may be present. If the abscess ruptures into 
the lung, the sputum assumes the characteristics noted 
under "contents of liver abscess," and may contain the" 
actively motile ameba. Nausea and vomiting occur as 
a sequel of the diseased condition of the liver. 

As a rule, there is no distinct jaundice ; the patient 
acquires a yellowish tinge which more resembles that 
seen in the cachexias, such as carcinoma, than a true 
jaundice. Dorsal decubitus is assumed, with flexion of 
the right thigh. The right rectus is rigid. There is 
tenderness over the area of hepatic dulness. The respi- 
ration varies ; if the abscess be deep there is no change 
from the normal ; but if it be superficial, with perihepa- 
titis, respiration is thoracic and shallow. According to 
Smith,™ functional dyspnea is pre.sent, especially in those 
cases involving the right lobe posteriorly. 

The diaphragmatic shadow varies, depending upon 
hether or not adhesions are present, the former giving 
more favorable prognosis. If the abscess is near the 
irface, anteriorly, there may be present some local 
ilging and edema. The area of hepatic dulness, espe- 
lly if the abscess be near the surface, is enlarged (see 
iS I, II, III). The direction of the increase in area 
" is dependent upon the location of the abscess. As a rule, 
there is no change in the splenic dulness. Enlargement 
of the giistric and hemorrhoidal veins is not a usual 
complication. Little work has been done on the diag- 
nostic value of skiagraphy, but Kelsh and Niemier" be- 
lieve it of importance in the diagnosis of adhesions, and 
Ilolleston '» states that the liver shadow is displaced 
upward and does not move with respiration. 
ML The Blood : All authorities insist upon the diag- 
^fcetic value of leukocytosis. Osier" believes that the 
■^ree is moderate in practically all cases. Scheube" 
^eaks particularly as regards its usefulness in the differ- 
entiation of liver abscess from malaria. Rogers," whose 
work is especially instructive, believes that the leuko- 
cytosis is more marked in small, deepseated abscesses, 
and concludes : 1. That absolute leukocytosis is nearly 
always found in amebic ab.scess of the liver, but rarely 
in chronic cases with marked anemia, when only a rela- 
tive leukocytosis exists. 2. The degree of leukocytosis 
is very variable, being highest in the most acute cases, | 




while a low degree is commonly met in cases with 
insidious onset, in which repeated examinations may be 
necessary. 

Unfortunately, in some of the earlier cases of my 
series no leukocyte count was made. Those in which it 
is noted previous to operation follow : 



Case. 


Number of Counts. 


Number of Leukocytes— Average 
per Count. 


• { 

2 


A. Thirteen 

B. Two 
One 
Six 
Two 
Four 
One 

Thirteen 
Fourteen 
Seven 
One 
One 
One 
Seven 
Two 
One 
One 
Five 


28,730 first admission. 
15,100 second admission. 
12,800 
11.600 
28,100 
14,S00 
26,300 
23,800 
19,000 
21,300 
7,280 
14,900 
13.160 
26,400 
42,350 
12,600 
21,(.00 
20,500 


3 


i 


11 


13 


14 


15 


18 


22 


23 


26 


28 


31 


32 


33 


84 




Total.... 


Eighty-two 


21,500 



From these I am forced to conclude that as a rule the 
leukocyte count is somewhat higher than Osier has 
pointed out and to believe with Rogers that it is almost 
always marked, though what relative degree is present 
in those cases in which a low count is recorded I am 
unfortunately unable to say as no count of the red blood- 
corpuscles was made. No difference in count existing 
between the first and second admission of Case I is of 
interest. 

The urine a rule presents nothing characteristic, 
though Pfahler^' has described crystals, in form resemb- 
ling tyrosin, but more tapering, in one case. 

Complicaliom. —Mention will only be made of the 
more frequent. Amebic dysentery may be placed under 
this heading as well as under the etiology. 

Perihepatitis and local peritonitis as complications 
are welcome ones, the subsequent adhesions by binding 
the liver surface to the diaphragm render much less the 
probability of infection during operation or manipula- 
tion. Godlee" says that perihepatitis is almost an 
invariable accompaniment and always exists when the 
abscess reaches the surface. Involvement of the lung, 
either through the diaphragm or by direct rupture, 
partakes first of the nature of a pleurisy and later of a 
pneumonic condition of the base. 

Termination.— The abscess not being operated upon 
may rupture as follows : [Table of von Rendu, quoted 
by Scheube.^ 





i 


a 

s 

s 

T. 


i 
P 

V 


a 
a 


a 
e 

a 
1 


d 
o 

8 


•0 

a a 

«a 


u 


i 
s 

a 
> 


00 

a 
■a 

5 
2 


« . 

ir a 

at 






& 


b 




< 




oo 


OS 

O 


a 


Waring 








28 
10 


15 


2 
1 


1 

J 


1 


8 


2 

i 


Dutroulau 


66 





? 


Kouls 


162 


1 


11 


17 


14 


n 


Q 


2 






Hasper 


25 
10 




4 


2 
2 


2 

1 

39 


A 


~ 


1 
4 


3 


f 






— 




— 




563 


1 


31 


59 




Per cent 




.13 


5.5 


10.5 


6.9 


1 


1.4 


•7 


.6 


.3 






* 



ZHagnosig.—M&l&rial Fever : This is more often con- 
founded with liver abscess than any other disease, but 



140 A^MEKicAN MEDioxNBi CYST OF KIDNEY SIMULATING OVARIAN CYST 



C January 27, 1906 
Vol. XI, Mo. 4 



the absence of periodicity in the temperature, the high 
leukocyte count, the local pain and the probable history 
of dysentery render a diagnosis comparatively simple. 

Malta Fever : This was the original diagnosis in Case 
II upon admission ,to the Division Hospital, but here 
again the local symptoms and the leukocyte count ren- 
dered the determination of suppuration possible. Em- 
pyema is a condition not to be overlooked especially if 
the abscess ruptures into the pleura. 

Appendicitis with referred pain may be confounded, 
as are also at times affections of the gallbladder. 

An unresolved pneumonia may give somewhat simi- 
lar symptoms. 

Prognosis. — Manson • gives as the mortality for the 
Indian army during the period 1891-94 as 57.7 /«,. Of 
•my 34 cases 16, or 47^, terminated fatally. 

The cause of death may be from the associated dys- 
entery, septicemia or intercurrent disease. Strong " cites 
four cases in which copious intestinal hemorrhage was 
terminal. The series of Councilman and Lafleur '" gives 
one more case ; and in Case V of my series this was the 
■determining factor. 

Treatment consists of evacuation of the cavity, and at 
present there are two accepted methods of procedure. 
A great number of men believe in evacuation, where 
feasible, by means of a trocar, the puncture being made 
in the eighth or ninth interspace, and the insertion 
through the trocar of a rubber tube, which is allowed to 
remain in situ for drainage. The other method is inci- 
sion down to the liver, location of the cavity by palpa- 
tion or aspiration, followed by incision and drainage. 
The latter, in the light of modern aseptic surgery, seems 
the more rational. Acidulated solutions of quinin sul- 
fate, I to 600, are recommended for irrigation of the 
cavity after adhesions have formed. 

CONCLUSIONS. 

1. This condition should be known as hepatic ame- 
biasis, the words "tropical" and "single" both being 
faulty in describing it; furthermore, it is not a true 
abscess as we understand the same. 

2. The ameba coli, LQsch, is the exciting cause. 

3. The routes of infection are the portal vein, over 
the peritoneum from the gut to the liver by ameboid 
motion, and through the common bile duct. 

4. The leukocyte count is comparatively high and 
always a valuable guide in the diagnosis. 

BIBLIOGRAPHY. 

1 Manson : Tropic Diseases, 1903. 
•Osier: Johns Hopkins Hosp. Bull., Vol. i, 1890. 
•Wooley and Musgrave: Bull. 32, Bureau Gov't Ijab., 
Manila, June, 1905. 

« Rogers, L. : Brit. Med. Jour., Vol. ii. 1902. 

5 Aruott : Brit. Med. Jour., Vol. i, 1903. 

6 Amberg: Johns Hopkins Hosp. Bull., December, 190X. 
' Malbot: Arch. Gen. de Med., Vol. ii, 1899. 

sKelsh and Niemier: Bull, de I'Acad. de Med., March, 

1900. 

'» Kartulis : Zeitsoh. fur Hyg. und Infectkrank., liXM. 

'0 Rolleston : Diseases ol the Liver, Gallbladder, and Bile 
Ducts, 1904. 

" Buchanan : Jour. Trop. Med., Vol. i, 1899. 

12 Kruse and Pasqual : Zeitsch. fur Hyg., Bd. 16, 1894. 

"Dopter: Annal de I'lnstltut Pasteur, July, 1905. 

" Jurgens: Beobachtungen u. TJntersuch. utaer d. Ruhr. 

" Rogers : Brit. Med. Jour., Vol. i, 1903. 

'« Bassett-Smith : Brit. Med. Jour., Vol. ii, 1900. 

"Rogers: Jour. Trop. Med., August, 1905. 

"Pel : Berlin, klinische Wochen., April, 1904. 

"Keble: Brit. Med. Jour., September, 1902. 



20 Smith : Brit. Med. Jour., Vol. ii, 1900. 
2' Osier: Med. News, April, 1902. 

^^Scheube : Die Krankheiten der Warmen Lander, 1903. 
"Pfahler: N. Y. Med. Jour., February, 1902. 
"Godlee: The Lancet, May, 1902. 

"'Strong: Bull. 32, Bureau (iov't Lab., Manila, June, 1906. 
26 Councilman and Lafleur: Johns Hopkins Hosp. Reports, • 
Vol. ii, 1891. 

CYST OF KIDNEY SIMULATING OVARIAN CYST.' 

BY 

WILMER KRUSEN, M.D., 

of Philadelphia. 

Professor of Gynecology In Medical Department of Temple College. 

The following case is one of simple serous cyst of the 
right kidney, which from the diagnostic standpoint re- 
sembled a cyst of the right ovary with a long pedicle. 

The patient, Mrs. W. C, aged 34, was referred to me 
by her physician, Dr. Joseph Swartzlandcr, of Forest 
Grove, Pa., and was admitted to the Samaritan Hospital, 
March 13, 1905. The following history was elicited: 

Family History. — The mother died of nervous pros- 
tration at 60. One sister died of acute articular rheu- 
matism; another of erysipelas following a burn. The 
father and two brothers are well. Otherwise no chronic 
disease in the family. 

Previous History: — Patient has had measles and 
whoopingcough. When 15, she had an attack of acute 
articular rheumatism, and since then has experienced 
several slight attacks. Puberty occurred at 12, and 
the menses were regular, though painful before mar- 
riage. She has been married 13 years and has two 
children, the youngest aged 3. The labors were normal. 
Since her eighteenth year, the patient has suffered with 
sharp lancinating pains in the right side which were re- 
lieved by lying down, except on two occasions. Varia- 
tion in daily quantity of urine was not noticed. During 
pregnancy the attacks of pain did not occur but always 
recurred after delivery. After the birth of the youngest 
child, the attacks of pain were renewed and a steadily 
growing mass was discovered in the right abdominal 
cavity. This mass was movable and according to her 
statement "traveled all over the right side." 

One week before entering the hospital, the size of the 
mass apparently decreased and led the patient to hope it 
would disappear. Instead, it rapidly attained its former 
proportions. Attacks of sharp pain no longer occurred, 
but a steady ache persisted. Menses were regular and 
painless and bowels regular. 

The urine was normal in appearance, of pale color, sp. 
gr. 1010, and the reaction acid. There was no albumin 
nor sugar present and tlie microscopic examination was 
negative. 

Operation was performed on March 14, 1905. A 
median incision revealed a cyst about the size of an or- 
dinary football occupying the right side of the abdomen 
and having no connection with tlie uterine appendages. 
The cyst was retroperitoneal, and after making a small 
incision into it a quantity of clear, colorless fluid was 
evacuated. The walls of the cyst were very thin and 
tense and of a transparent bluish color. On examina- 
tion it was found to be connected with the right kidney, 
which was considerably atrophied. No odor of urine was 
detected. 

A second incision was then made, about 2 inches in 
length, in the right iliac fossa. After the removal of a 

• Read before the Philadelphia Obstetrical Society, May 14, 
1905. 



jA.NtrARY 27, 19061 

Vol. XI, No. 4 J 



CYST OF KIDNEY SIMULATING OVAEIAN CYST jaherican MEDirrNK Ul 



portion of the sac for microscopic examination, the re- 
mainder was sutured to the incision to the deep layer of 
the fascia, and an iodoform gauze drain introduced. 
The gauze was removed in four days and a solution of 
methylene blue injected into the sac for diagnostic pur- 
poses; but as the urine remained uncolored it was con- 
cluded there was no communication with the pelvis of 
the kidney. Later the sac was swabbed out with a solu- 
tion of carbolic acid and a drainage tube inserted for a 
finv days longer until the drainage entirely ceased and 
ihc secreting sac was apparently obliterated. The symp- 
tom of pressure disappeared. The patient made an un- 
eventful recovery and left the hospital on April 9. 

According to Morris there are several forms of cyst 
'f the kidney. (1) The small and numerous cysts which 
occur in granular kidney and which are of pathologic 
lather than clinical importance, as they never give rise 
to a marked tumor and are not amenable to surgical 
M-catment. They are in fact retention cysts which re- 
iilt from compression and constriction of the urinary 
ubules, due to the sclerosis which follows interstitial 
nephritis. (2) Dermoid cysts which are extremely rare. 
Alorris has never met an instance of such a cyst in Ihe 
luman body. Cases, however, have been reported by 
Paget, Madelung, AValker and Biggs. (3) Simple serous 
'■\-sts. (4) Conglomerate cysts or polycystic disease in 
liich the whole kidney is converted into a nniriber of 
conglomerate cysts of varying size which leave un- 
changed scarcely any of the glandular strncturn and give 
greatly increased bulk to the metamorphosed organ. 
(5) Hydatid cysts. According to Bland-Sutton the 
'ivdatid may attain a very large size and load to an ev- 
nsive atrophy of the renal tissue. When small they 
rarely give rise to trouble or inconvenience during life 
and their existence is only detected in the course of a 
postmortem examination. There are good reasons for be- 
lieving that the greater number of hydatids of the kid- 
ney rupture into the pelvis of the organ, the fluid and 
^ osieles passing down the ureters and being discharged 
through the urethra. As the formation of a hydatid 
cyst is the result of the entrance into the body, of the 
ova of Taenia ecldnococcu^ of the dog, they occurin those 
untries where men and dogs are brought into intimate 
association and are especially common in countries 
where the poorer classes use dog flesh as food, or eat from 
the same plates as the dogs, i. e., Iceland, Mecklenburg, 
and Silesia. (6) Paranephric cysts, or cysts which are ex- 
^rnal to the capsule of the kidney and are formed in the 
cumrenal fatty^tissues which are intimately adherent 
the organ and sometimes communicate with the 

The case reported was shown by macroscopic examina- 

to belong to the third class of simple or serous 

ts. These cysts are not very frequently found, 

ekel having collected but 21 eases out of the whole 

^rature from the year 1865 to 1899. In the Hunterian 

seum there are three specimens of this sort, and prob- 

■ many eases have been unrecognized, as they cause no 



symptoms except those due to pressure; and according 
to Morris not one-fourth of them reach a size to attract 
attention during life. They vary in size from that of a 
walnut or orange to that of a large ovarian cyst. Their 
origin is in the cortex of the organ and they project in 
relief from its surface. The rest of the kidney may be 
healthy and functionally active; or it may be more or 
less atrophied from the pressure of the cyst itself as in 
the case reported. The contents are generally clear or 
straw-colored, containing a small quantity of albumin 
and a little saline matter, but rarely, if ever, anything 
more than the merest trace of urea or othGr special 
urinary ingredients. Hemorrhage may take place into 
the cavity of the cyst, either as the result of injury or of 
extravasation from the veins which ramify in the cyst 
walls. These cysts are more frequently found in women 
than in men. TufEer gives the proportion as 20 to 3. 
They occur in either kidney alike, but are rarely bi- 
lateral. 

Simple renal cysts grow slowly, and do not as a rule 
attain a size sufficiently great to give rise to a tumor; 
but a cyst may increase so as gradually to monopolize 
the greater part of the abdominal cavity. If so, "its 
point of attachment ceases to be even approximately as- 
certainable and in the female it may give rise to the idea 
of an ovarian tumor" (Morris). Pain may follow the 
formation of the tumor and it is usually of a dull, aching 
character, giving rise to a sensation of weight limited 
to the region involved. At times, especially after much 
exertion, the pain may be more severe. 

In this case the pain was not present during preg- 
nancy nor when the patient was reclining, as probably the 
dragging sensation was relieved at those times. 

The difficulty in diagnosis is apparent from the casea 
recorded. Examination of the urine gives no information. 
If seen early it may be mistaken for hydatid kidney, for 
hydronephrosis and other renal tumors, also for hepatic 
or splenic cysts, or cysts of the omentum, mesentery or 
pancreas. Later, as the cyst develops and the tumor oc- 
cupies the lower portion of the abdomen and pelvis, it is 
very apt to be mistaken for an ovarian neoplasm. Five 
cases have been reported in which this natural mistake 
was made. 

The treatment is varied. (1) The treatment by punc- 
ture which was recommended in earlier days of renal 
surgery should no longer be employed, as it is uncertain, 
not free from risk and the cyst usually refills. (2) In- 
cision with drainage. The edge of the cyst is stitched 
to that of the wound and the secreting surface may be 
destroyed with pure carbolic acid or nitric acid. Partial 
and total nephrectomy have been employed, but accord- 
ing to Morris should be reserved for cases in which the 
cyst is of voluminous size and has in great part de- 
stroyed the renal tissue. Tuffier has collected 31 cases 
in which nephrectomy has been performed; 7 times by 
the lumbar method with a mortality of 11 %; and 24 



142 Ambbican Mkdicinki 



PULMONARY TUBERCULOSIS 



[January 27, liioe 
Vol- XI, No. 4 



times by the transperitoneal method with a mortality of 
40 %. This seems a sufficient argument in favor of the 
slower and more conservative method of treatment by in- 
cision, drainage, and gradual obliteration of the secret- 
ing sac. 

THE TREATMENT IN THIS VICINITY OF PULMO- 
NARY TUBERCULOSIS.' 

BY 

HAMILTON D. WEY, M.D., 

of Elmira, N. Y. 

In the latter part of July, 1904, I was consulted by 
the Rev. H. L. O., of Steuben county, aged about 35, 
and of native birth. The history given was that of grad- 
ual physical deterioration of about two years' duration, 
accompanied by cough and expectoration, embarrassed 
breathing, quickened pulse, and night sweats ; the latter 
conditions singly and severally for a year or there- 
abouts, or until the subject of this sketch was incapaci- 
tated for the exercise of his pastoral duties. A physical 
examination revealed a man of large frame, but anemic 
and with shrunken muscles. The cheeks were flushed 
in a manner to suggest fever. Temperature 100°, respi- 
rations 26, pulse 100. Digestion was impaired and there 
was occasional irritability of the stomach. There was 
flatness over the region of both scapulas, extending out- 
ward to the axiliary line. On the right side the flatness 
extended to the apex of the lung. On both sides were 
moist rales. The clinical picture was that of pulmonary 
tuberculosis. The diagnosis, however, was not confirmed 
by an examination of the sputum, owing to my depart- 
ure the following day upon an extended vacation. The 
patient was advised to withdraw from all active work. 
Directions as to dietary and living, together with rest 
during febrile periods, and life in the open air, were 
given, and a residence advised near home upon some 
hill at an elevation above the fog line. The patient 
passed from my notice until January of the present year, 
when he again appeared at my office. Improvement 
had taken place to such a degree that I did not at first 
recognize him. There had been a marked gain in 
weight and strength, disappearance of the hectic flush 
and night sweats, dyspnea, and a return of temperature 
and pulse to normal. There was little or no expectora- 
tion. The rales previously noted had disappeared, and 
bronchial breathing was normal and unaccompanied by 
adventitious sounds. Pains previously complained of in 
the chest were absent ; respirations regular and naturally 
performed. The apex of the right lung had cleared, and 
in the region of the scapulas percussion elicited resonance 
but slightly below the normal. Over these regions the 
vesicular sound was somewhat muffled and in a few 
small circumscribed areas absent. The mode of living 
followed in the interval between the first and second 
visits is best told in the words of the patient, whom I 
quote : 

June 17, 1905 : " When I visited you last July I was 
having night sweats ; a red spot on each cheek mornings ; 
was losing a pound a week regularly ; strength was so 
far gone as to be unable to do over a half hour's work at 
a time. I had a severe cough at times for three or four 
weeks and then it would let up. Was unable to sleep at 
night. Chest was sunken in ; pulse high ; severe pain 
in each lung, at times difficulty in breathing. You 
probably remember telling me that my lungs were 
solidifying, that I was using my right but little and the 
left was in bad shape. This was also stated to be my 
condition by a physician from Washington, D. C, and 
one from Florida. I could not take three deep breaths 
without causing pain. The general remark at home was 

1 Read at a meeting of the Lake Keuka (N. Y.) Medical and 
Surgical Association, June 14, 1905. 



' how bad you look ; how fast you are going down.' 
You told me that in six months I would i)e a complete 
physical wreck, as did the two physicians already men- 
tioned. As to my condition today, 1 have driven my 
team all the spring from nine to ten hours a day, and in 
addition, did chores about three hours. 1 was out every 
day during the winter driving my team lumbering. 
My lungs only pain me at times when we have a bad 
atmosphere ; at such times it is hard for me to breathe. 
I have no fever, no red spots on my cheeks, no night- 
sweats. Sleep like a log ; some nights do not wake up. 

1 still have my off days, but not so far off as formerly, 
and work all the time, where I used to go to bed in fore- 
noon and afternoon. I am near my normal weight, 
scarcely any cough. People now say, ' how you have 
gained ; how fat you are ; you do not look like a wreck 
now.' As to my mode of living, have lived in a tent 
since last September, ate in it, slept in it— my wife and 
I. I had a wood fire in the tent during the day and let 
it go out at night. Opened the end of the tent where 
the bed set and allowed the wind and snow to blow on 
us all night. Some mornings there would be a bank of 
snow as high as the bed to jump out in. We used flan- 
nel blankets, outing flannel nightrobes, but no night- 
caps, and less covering than any winter in our lives. We 
took off all underwear at night, but wore wool during 
the day. I took a cold water bath twice a day for a 
long time, but now only at night. I ate beefsteak 
twice a day and cold beef or cheese for supper. Took 
a glass of cream three times a day, also six to twelve 
raw eggs. I ate lots of fruit— about 500 pounds of 
grapes ; had them all winter. Also peanuts and other 
nuts. I went bareheaded until I nearly froze my ears. 
Wore my shirts unbuttoned and chest bare all winter, 
or until winter was nearly gone. Took my exercises 
regularly three times a day, but only once now, as I get 
so much exercise in my farm work. I think it safe to 
say I have done as much as any man around, and more 
than some who have a hired man ; and I am now ahead 
of any man with my work. I sowed 31 acres of oats, 
planted 5 acres of potatoes, and have ground nearly 
ready for planting 10 acres more. Have had help three 
days. I forgot to say we are about 1,750 feet above sea- 
level. Bluff Point is less than 1,450 feet. I eat a great 
deal of butter, but no pie or cake, and drink neither tea 
nor coffee. My weight was 158 pounds last summer 
and 184 this spring, and no fluctuations, a steady gain. 
My tent is a 10-oz. duck, 8 ft. wide by \^ ft. long, with 
4 ft. wall. Hemlock floor on an average of more than 

2 ft. above ground. Our stove was a small ' chunk ' 
stove about 3 ft. high, 18 in. long, and 14 in. wide, 
with one opening on top. As to medicine, I took Dr. 
Crittendon's cascara tablets for a laxative. I used ben- 
zoylacetylperoxid as an inhalant for about half the 
winter, as I had my nose cauterized five times and 
throat once. I used this until the parts seemed sound 
and not for my lungs. This is all the medicine of any 
description. Took the raw eggs in about two table- 
spoonsful of sherry wine. I tried other ways and even 
port wine, but they all made me sick. Have had a 
great deal of that sick, nauseating feeling, and at first 
would be so awful tired it was something dreadful. 
How tired I would be on my off days ! I have that yet 
at times, but nothing like last summer. I have never 
once thought that work hurt me, but on the con- 
trary have firmly believed it to be one of the leading 
features in my recovery, especially work in which one 
is in all positions, doing all kinds of work, easy and 
violent. There is no tuberculosis in our family on either 
side." 

It is worthy of remark that the wife who shared the 
work and life of her husband, as narrated, gained over 
12 pounds in weight. 

The only criticism of the letter is that the writer 
labored too hard last winter and spring. But, on the 



JAN0ABY W, 19061 
Vol.. XI, No. 4 J 



PULMONARY TUBEECUL0SI8 



AMERICAN Medicine 143 



other hand, the farming operations referred to, and 
which in ray judgment are responsible for, at least in 
part, the " off days " mentioned, may have served a 
purpose in eliminating the element of depression of 
spirits and homesickness that would with almost inevit- 
able certainty have attended the removal from a life of 
activity among men to a monotonous farm life in a 
remote region. If physical conditions permit, occupa- 
tion within bounds is a therapeutic agent of value. Mt. 
Washington, the seat of my story, is a few miles from 
Hammondsport. In this connection, reference may be 
made to Bluff Point, 1,450 feet elevation, where a tuber- 
culous subject a few years ago endured the rigors of 
winter and the heat of summer in a tent with incal- 
culable benefit to himself. 

This paper is presented in affirmation of the argu- 
ment that patients with incipient pulmonary tubercu- 
losis, those susceptible of response to treatment, can be 
treated from the standpoint of climate as satisfactorily 
in this vicinity and contiguous territory on the high- 
lands above the fog line as in the Adirondacks, at Lib- 
erty, in Sullivan county ; or localities in Colorado, 
Arizona, and New Mexico characterized as health resorts, 

' and for years the objective points of the tuberculous. 

[ The same limitations, however, obtain in this vicinity as 

i elsewhere. Advanced cases and cases in which treat- 
ment has been deferred everywhere pursue a common 

I course to inevitable dissolution. The increasing number 
of private sanatoriums for the tuberculous and the estab- 

• lishment of State hospitals for the treatment of incipient 

': tuberculosis, as at Rutland, Mass. ; White Haven, Pa. ; 

: Glen Gardner, N. J. ; and Ray Brook, N. Y., must be 
accepted as an earnest of growing faith of ability to treat 
successfully in the earlier stages cases of the kind under 
consideration in the eastern and middle States. The 

■ . efiiciency of high altitude is no longer considered an 
essential, and exile to distant points, with severing of 
home ties, separation from friends, nostalgia, together 

1; with uncertainty as to duration of sojourn in distant 
places, coupled with doubt as to the ultimate ability to 
resume former modes of living, are not the factors they 
formerly were in embarrassing treatment. Homesick- 
ness nearly demoralized the troops of Napoleon the 
Great in Egypt. I believe if the history of large 
numbers of the tuberculous of the past sent to Col- 
orado and other western points were really known, 
nostalgia would appear a? contributing to mortality 
second only to the lesion of the lung. In the light of 
present understanding the essentials of successful treat- 
ment obtain equally in the east as in the west. They 
lire outdoor air without stint, proper housing, appro- 
priate and liberal nourishment, as indicated, together 
with intelligent supervision. Chemic therapeusis is of 
-<(;ondary value, applicable to special conditions and 
symptoms as they present themselves, and is not the 
Miiiinstay of treatment. I am not advocating the advan- 
tages of this or that locality in the treatment of incipient 
piilmonary tuberculosis, but am contending for, so to 
[H'ak, the home treatment of the disease in its early 
stages at points not far removed from where the disease 
Mther developed or was recognized. In other words, 
lie disease can be successfully treated under the same 



barometric and thermal conditions as prevailed at the 
time of its development, and without complicating treat- 
ment by the doubt and distress of mind as to future 
ability to return to the place of home residence endeared 
by family ties and interests. A residence at a point of 
elevation of from 1,400 to 3,000 feet is preferable to one 
of 5,000 or more, with generally attendant dyspnea and 
accelerated pulse. Wherever treatment is had, whether 
in the Adirondack region or the uplands of the middle 
or southern portions of the State, the patient should be 
brought to understand fully that tuberculosis, even in its 
early stages, is a severe disease and may require months 
or a year or more for its successful treatment. In the 
very nature of things improvement cannot be expected 
within a few weeks. Such being the case, the patient 
should be fully informed as to the precise nature of his 
disease, that the extreme of his cooperation may be 
secured, and which he will the more willingly render, 
under the realization that his life is at stake. It is a 
mistake to lull into a feeling of false security by the 
application of the term "lung fever," "pulmonary 
catarrh," and other misleading and erroneous terms. 
Without the patient's cooperation the efforts of the phy- 
sician will prove of little avail. 

It is not necessary in this connection to discuss the 
pros and cons of institutional treatment. Institutions 
furnish a haven for many who otherwise would not 
receive indicated and supervised treatment. But insti- 
tutions are not a sine qua non. Single and solitary cases 
under hygiene in all that the term implies, and intelli- 
gent supervision, will as readily respond to efforts in 
their behalf. Public institutions are not available for 
all through paucity of accommodations, and private 
sanatoriums are beyond the resources of many of our 
patients. But other than these, whatever place is 
selected for residence during the period of invalidism 
and treatment, the fact must not be lost sight of that 
country life and outdoor life are not synonymous terms. 
A farm house may prove an undesirable place of resi- 
dence, and a bedroom there contraindicated for occupancy 
by a tuberculous subject. Indoor life on a farm or in the 
country is as objectionable as a life passed indoors in the 
town. So far as relates to environment, the text 
repeated and reiterated is fresh air and a life lived out 
of doors. Outdoor life in sunshine and cloud, tempera- 
ture high and low, rain and snow, day and night, is the 
golden rule. A stuffy and unventilated bedroom will 
negative all other agents for good. Shelter should be 
had from the direct rays of a fervent sun and high 
winds, lest the latter abstract warmth from the body. 
An unfounded prejudice unfortunately exists against night 
air. In localities such as are under consideration, night 
air possesses no contraindications or malign features. Its 
chemistry is the same as that of day, the only difference 
being the absence of sun and light. Exercise is to be 
taken within bounds and the limit of fatigue, and vary- 
ing temperature met by varying clothing. The ordi- 
narily constructed house, farm, or otherwise, does not 
commend itself as an ideal or even indicated place of 
abode for the tuberculous. Happily, however, the 
problem of housing this class of invalids is best met at 
the present time by the employment of a lean-to tent 



Ui 



Ahkbicak MbdioinkJ 



ANTITOXIN EFFECTIVE IN SCARLATINA 



rjANUABY 27, 1906 
LVOD. XI, No. 4 4 



and a portable cottage, or the elaboration of all, com- 
bined. Reference may be made to the Tucker tent, 
Gardiner tent, Ulrich tent, the Adirondack tent house of 
Biggs, and the Walker portable cottage as instances of 
specially designed domiciles for the tuberculous. It 
does not follow that these cannot be improved upon. 
They represent, however, the best thought and expe- 
rience at the present time, and have to commend them 
their moderate cost, readiness of instalment, and facility 
of removal from place to place. This applies more par- 
ticularly to the housing of individual cases. 

To those interested in the phase of segregate treat- 
ment of the tuberculous of the indigent class by county 
and city authority, suggestive and valuable data can be 
found in a monograph published by the Committee on 
the Prevention of Tuberculosis of the Charity Organiza- 
tion Society of the City of New York, entitled " County 
and City Care of Consumptives— Some Methods of 
Housing." Of importance not secondary to outdoor 
living and proper housing is nourishment and dietetics. 
This is apparent when it is recalled that the most promi- 
nent first effect of pulmonary tuberculosis is progressive 
emaciation, and that disorders of digestion and nutrition 
precede for varying periods elicited pulmonary lesion. 
According to Cornet, the first aim should be to stay the 
increased metabolism, to make good the pressing deficit, 
and by heightened nutrition to cover the loss already 
incurred. Dietary must be adapted to the individual 
patient and not all the tuberculous can be placed upon 
an unvarying diet. An unlimited quantity of cod-liver 
oil and the injunction to eat well and drink much milk 
should not be the dietetic scheme. By such advice the 
patient is practically left to his own resources and imag- 
ination as to what he should eat or should not, and disap- 
pointment ensues in place of success. The story of the 
scales of increasing weight is a better gauge as to the 
measure of improvement than the patient's statement as 
to his feelings or any information gained from the lung 
through auscultation and percussion. 

It is unnecessary at this time, and would be presump- 
tion on my part, to present in detail a dietary for the 
tuberculous. None better than yourselves can appreciate 
the necessity fbr generous nourishment within the 
capacity of the patient to repair waste, make good loss 
and raise to the highest possible degree of efficiency the 
vegetative functions of the body. It is better to save the 
price of railroad fares to distant points in quest of health 
and spend the equivalent hereabouts in generous and 
indicated foods, as it is proved that tuberculosis can be 
treated under favorable conditions on the hills of Yates, 
Steuben, Allegany, Chemung, and Broome counties, 
also other counties of New York. Patients with this 
disease should not be sent upon long journeys into exile 
at distant points to the depletion of their means, but 
rather their resources should be reserved for home treat- 
ment and expenditure for more bountiful and appro- 
priate diet than that afforded by boarding houses and 
places of entertainment to which they find their way. 
We have at our doors and at our command all that is 
necessary for the treatment of recent tuberculosis. In 
advanced cases death will occur anywhere. May we 
not say or permit our patients to exclaim as did the 



Syrian captain, "Are not Abana and Pharpar, rivers of 
Damascus, better than all the waters of Israel ? may I 
not wash in them, and be clean ? " 



DIPHTHERIA ANTITOXIN EFFECTIVE IN 
SCARLATINA. 

BY 

J. H. LOPEZ, M.D., 

of Philadelphia. 

Medical Director of Charily Hospital, Philadelphia ; Visiting Physi- 
cian SI. Vincent's Home, etc. 

In calling attention to the value of diphtheria anti- 
toxin in scarlatina, my object is to suggest that other 
physicians cooperate in giving the remedy a thorough 
trial, since my results have been so favorable and there 
are neither contraindications nor undesirable after- 
effects. 

About three years ago, in an orphanage containing over 
300 children, there were many cases of scarlatina follow- 
ing an outbreak of diphtheria. To guard against the 
dangers of extensive mixed infection and for immuniz- 
ing purposes antitoxin was liberally employed. The uni- 
form dose, in all cases in which the diagnosis of diph- 
theria could not be made, was 1000 units. The effects 
of the remedy upon all the children then showing 
evidences of disease, as compared with those common 
to the antitoxin treatment of diphtheria, is a matter of 
vital professional interest. Too great stress cannot be 
laid on these favorable results in the non-diphtheric 
cases. 

It is admitted that a few may have been of a mixed 
character and that in such, the results noted were due 
to the prompt and complete neutralization of the ab- 
sorbed diphtheria toxins. But all the cases under con- 
sideration were not of a mixed character. Many cases 
were without doubt scarlatina, having been closely ob- 
served by Drs. Charles A. Groff and Sylvester J. Deehan, 
of the Municipal Board of Health, and Drs. Samuel 
Wilson and Frederick Eft and myself, of the medical 
staff of the institution. 

More than this, these cases were in the main, scarla- 
tina, pure and simple, in its various forms, and the 
diagnosis easy enough. In every case the results were 
favorable, but they were especially so in the anginose 
type. In the early stages it is difficult to distinguish 
diphtheria from scarlatinal sorethroat, ulcerative ton- 
sillitis, laryngeal diphtheria (membranous croup), and 
other kindred throat lesions, all of which are ushered in 
with a chill, fever, swollen glands, enlarged tonsils, 
edema of the, fauces, pain and general malaise, varying 
in intensity according to the previous condition of the 
victim, or the virulence of the exciting cause. 

Tlie close resemblance of one or all of these conditions 
to diphtheria must always modify the value of early 
observations, as to the effects of treatment, when there 
is still a reasonable doubt as to the correctness of tho 
diagnosis. But this, I contend, applies only to the 



January 27, 19061 
Vol. XI, No. 4 J 



CHRONIC ENLARGEMENT OF THE TONSILS 



[Ambbican Mbdicinb 115 



earliest stages, as it does in mixed infection. As a case 
progresses, the matter of diagnosis tends to simplify 
itself. This is especially applicable to all sorethroats of 
scarlatinal origin. 

In the scarlatinal anginas the seat of the inflamma- 
tion is in the fauces or nasal passages, and the grayish- 
^^•hite, or yellowish-brown membrane is usually confined 
to the tonsils or lateral pharyngeal surfaces. On the 
other hand, in diphtheria, the membrane is generally 
on the uvula and the posterior faucial arches. The in- 
volvement of the uvula is of special diagnostic value. The 
membrane may be on the anterior aspect alone, or 
imilarly only on the extreme posterior aspect. 

In scarlatina the appearance of gangrene adds ma- 
terially to the resemblance of the local lesion to the 
iseudomembrane of diphtheria. In pultaceous pharyn- 
:itis likewise, the membrane resembles, in general ap- 
icarance, the genuine diphtheric membrane ; but in both 
onditions the similarity is superficial and more ap- 
parent than real. The membrane is always soft and 
pliable, and is removed with the utmost ease without 
leaving a bleeding surface. It appears in patches, as a 
rule, and is apt to be confined to the tqnsils and the ad- 
jacent pharyngeal surfaces. It presents intervening 
erosions which are in marked contrast to the smooth 
continuity and more elevated appearance peculiar to 
diphtheria. 

In rare cases the resemblance to the membrane of 
diphtheria is so close as to sustain a doubt as to the 
proper clinical diagnosis till the appearance of the char- 
acteristic scarlatinal rash, which may be delayed beyond 
the usual 24 or 48 hours. Again, the case may be ex- 
ceedingly mild and terminate without a rash. In such 
instances, the subsequent appearance of nephritis in an 
infected household, a sequel common to the two diseases, 
is likely to be tlie only clinical evidence that the case was 
one of scarlatina. 

The similarity of many of the symptoms of scarlatina 
and diphtheria, apart from the eruption, may explain 
in part the favorable action of antitoxin in both condi- 
tions, in addition to the accepted theory of mixed or 
superadded infection. The difficulties in the way of an 
early bedside diagnosis suffice to emphasize the supreme 
importance of prompt administration of adequate doses 
of antitoxin. 

Early curative doses of antitoxin abort the disease, 
rnrtail suffering, and lessen the risk to the patient. For- 
tunately, in my experience, this applies to the scarlatinal 
infections as well as to the diphtheric. Pain is relieved 
and the course of the disease cut short, and perhaps the 
medical attendant prevented from an unfortunate diag- 
nosis. 

One dose, of say 2000 units, would be sufficient in the 
average case of sorethroat, due to bacterial infection, to 
effect a speedy cure. There are no contraindications and 
only good follows such practice. 



It must be remembered that the curative value of diph- 
theria antitoxin is not restricted to removal of the pseu- 
domembrane. It is equally effective through neutraliz- 
ing the toxins in reducing fever and local congestion 
which contribute to the patient's suffering and the ele- 
ment of danger. This latter applies to all anginas be 
they scarlatina, diphtheria, tonsillitis, quins3% etc. In all 
throat lesions the serum has proved a most effective anti- 
pyretic without adding a single element of danger. It 
should be remembered that the largest quantities of 
serum the most severe cases may require, running into 
20,000 to 100,000 units, are not depressing to the heart, 
nor is it attendant with any bad results or sequels. 

In all anginas, especially the large class usually 
designated scarlatinal, antitoxin aborts the febrile ac- 
tion and ameliorates the local lesion, which furnish 
climate and soil for bacteria. Such was the result in the 
institution referred to, and since in my private practice. 
In the cases which appeared, in the completed picture, 
to be uncomplicated scarlatina without a doubt the effect 
of the serum was distinctly curative, only relatively 
less pronounced than in the equally positive cases of un- 
complicated diphtheria. 

The cases demanding the administration of many 
thousands of units are comparatively rare, and even when 
the necessity for such treatment arises, the exigency 
should be preferable to the sum total of prolonged sick- 
ness, trained nurses, drug bills, with possibly a fatal 
termination. 

In hopes that others may employ the antitoxin treat- 
ment in scarlatinal cases, and in that manner more firmly 
fix its value, is my reason for publishing my results. 



CHRONIC ENLARGEMENT OF THE TONSILS AS A 
FACTOR IN ETIOLOGY.' 

BY 

C. P. NELSON, M.D., 
of Westbrook, Minn. 

Much has been said and written about the danger of 
enlarged tonsils. Their presence is readily recognized, 
and the treatment is simple and almost free from danger. 
Considering the frequency, however, with which dis- 
eased conditions resulting directly or indirectly from 
enlarged tonsils are met, it is evident that the importance 
of this subject is not duly appreciated. An observant 
physician will often notice signs of enlarged tonsils, 
faucial or pharyngeal, in those whom he is called to 
treat for other ailments, or in other children in the fam- 
ily who may not be ailing at the time, and if attention 
were called to this condition and the removal of the 
tonsils advised, together with other proper treatment, a 
great many would be spared much unnecessary suffering, 
and enabled to develop properly. 

The faucial tonsils are two almond-shaped bodies sit- 

' Read before the Southwestern Minnesota Medical Societv. 
June, 1905. ' 



146 Ahebioan HKDicnrKl 



CHRONIC ENLAEGEMENT OF THE TONSILS 



rjANCARV H, 1906 
LVOL. XI, No. 4 



uated between the anterior and posterior pillars. They 
are composed of adenoid tissue, with 12 to 15 deep de- 
pressions into Avhich the mucous membrane, covering the 
surface of the tonsil, extends. Their function is to help 
lubricate the bolus of food and thus aid deglutition. 
They also manufacture leukocytes. The pharyngeal ton- 
sil is a small adenoid body placed in the posterior part 
of the nasopharyhx. This is also covered with mvicous 
membrane and manufactures leukocytes. These 
bodies are very small and their function in 
the general economy very small, at their best. 
When chronicly enlarged they are more or less 
diseased and from their position obstructive, and 
what little of their proper function they can . 
then perform is insignificant in comparison with the 
mischief they cause. They interfere with nasal respira- 
tion, causing mouth-breathing with its attending evils. 
The inspired air passing normally through the nasal 
cavities is filtered, moistened, and warmed before enter- 
ing the pharynx. Coming through the mouth it is cold, 
dry, and laden with dust, producing a catarrhal condi- 
tion in the pharynx, larynx, trachea and bronchial 
tubes, lessening the resistance to disease germs, and pro- 
ducing a good culture medium. A somewhat similar con- 
dition is produced in the nasal passages and nasopharynx 
which, from a lack of proper ventilation, draft, and 
drainage, are converted into bacterial incubators. The 
Klebs-Loffler bacilli find a suitable field and diph- 
theria develops more readily. The germs of scarlet fever, 
measles, smallpox, pnexnnonia, tuberculosis, and other 
infective microorganisms find here a place peculiarly 
suitable for their growth and distribution. The swell- 
ing of the mucous membrane interferes still more with 
normal respiration. As Eeyburn says, "The power of 
destroj'ing microorganisms, possessed by the nasal mu- 
cous membrane, is lost, and the system is left in a condi- 
tion which renders it an easy prey to the attacking organ- 
isms. This fact is a weighty argument to be added to 
the long list that might be adduced in favor of breath- 
ing through the nose. Mouth-breathing, in fact, is al- 
ways a symptom of disease and shows that there is in 
the nasal passages some obstruction to the free entrance 
of air to the lungs. One of the most frequent causes 
of mouth-breathing is chronic enlargement of the ton- 
sils. When these are enlarged it shows that they are dis- 
eased, their protective power has been destroyed, and 
their crypts and follicles afford resting places for the 
lodgment of pathogenic bacteria and bacilli, and the 
distribution of their poisonous products to the system." 
Infection is readily carried from the nasal passages 
to the eye, including corneal ulcers and other infections 
as occurred recently in a case under my care, the patient 
suffering from corneal ulcerations, which would recur 
every few weeks. After the removal of the hypertrophied 
pharyngeal tonsil, ulceration of the cornea ceased to 
occur. Ziegler says, "I think we may safely say 99 % of 



corneal lesions take their origin directly from preexist- 
ent pathologic processes, affecting the intranasal tissues 
and secretions." 

The orifice of the eustachian tube is partly or wholly 
occluded from direct pressure or from the catarrhal con- 
dition. Hence, the function of this tube, as a ventilator 
and drainage canal for the middle-ear, is interfered with, 
and this, together with the extension of the infection 
into the middle-ear, causes otitis media, and frequently 
produces deafness and other complications, such as mas- 
toiditis, and even infection of the sinuses, meninges, and 
brain, and facial paralysis. In a case under my observa- 
tion two years ago, the parents refused the slight opera- 
tion necessary to remove adenoids from the naso- 
pharynx in a child of one year. Later they consulted 
me when there was evidently an acute otitis media de- 
veloping. This improving, they went away on a visit and 
while away the child became very sick and soon died 
from what the attending physician pronounced brain 
fever. It is well recognized that most of the cases of 
middle-ear disease in children are due to hypertrophy , 
of the pharyngeal tonsil. 

The absorption of toxins from the nasal and naso- 
pharyngeal cavities has much to do with undermining 
the general health. A condition of leukocytosis is often 
present. Respiration is labored, and the unnatural posi- 
tion of the mouth, face and chest leads to a deformity 
which is quite characteristic. There is the drooping 
jaw, high and narrow arched palate, alveolar contrac- 
tion, and chicken breast. The deformity of the alveolar 
process interferes with the teeth. They are irregular and 
crowded, and being hampered by the general lowered 
vitality, are often in a poor condition. 

Much of the septic material of the nasopharynx is 
swallowed and the rich bacterial cultures from the crypts 
of the hypertrophied, and necessarily diseased, faucial 
tonsils also enter the stomach and produce gastric dis- 
turbances, both functional and organic. 

In this diseased condition the tonsils, instead of acting 
as a barrier to the entrance of infection, rather favor it. 
Their mucous membrane is in an unhealthy condition 
and often ulcerated. Tubercle bacilli and other disease 
germs find a ready entrance to the tonsillar tissue where 
they have a good opportunity to develop in virulence and 
numbers. From here many of them pass on through the 
lymphatics leading from the tonsils, and we have tuber- 
culosis of the cervical glands, mediastinum, and lungs. 
Tuberculosis of the tonsils is not uncommon in pulmon- 
ary tuberculosis and good authorities have reconunended 
the removal of the tonsils as a routine prophylactic 
measure in this disease. According to Spartz, "Interest- 
ing autopsy reports show that an infection often results 
from a chronic, latent tonsillar abscess, by way of the 
lymphatics, and extending to the peritonsillar region, 
thence to the mediastinum, leading to pleurisy, pneu- 
monia, pericarditis or pyemia." Endocarditis may also; 



Jancaky 27, 19061 
Vou XI, No 4 J 



DIGEST OF MEDICAL LITERATURE 



TAmkrican Medicinb 147 



be produced in this mannei- and it is not uncommon to 
find valvular disease present in cases of chronic disease 
of the tonsils. 

When one thinks of the great number of disease germs 
in the air vro breathe and also in our food and drink, 
and then considers the position of the tonsils at the en- 
trance to the respiratory and digestive tracts, and their 
connection with man}' other parts of the body through 
the lymphatic system, it becomes evident that when in 
an enlarged and diseased condition they play a most 
important part as portals of infection. 

Baumgarten, Semon, Knxckman and Euge lay much 
stress on the part tonsils play in the causation of dis- 
eases. Myles says, "The recognition of the interdepend- 
ence of the tonsils and pathologic conditions in other, 
sometimes remotely situated parts of the body, repre- 
sents one of the important advances in medicine during 
recent decades. A variety of diseases has been traced to 
the primary involvement of the tonsils, among which 
are rheumatism, septic infection, tuberculosis, and in a 
recent report appendicitis and infective jaundice." 
Wood says, "From the little mass of postnasal lymphoid 
tissue may develop a startling aggregation of ills." 

Kaufman and others have shown that nasal obstruc- 
tion interferes with mental activity, inducing a condi- 
tion known as aprosexia. Nursing is sometimes ren- 
dered difficult or impossible; the breath becomes offen- 
sive, headache is often present and night terrors are not 
uncommon ; enuresis may occur ; the voice is often weak, 
dull and monotonous. When respiration is impeded, 
oxygenation is necessarily imperfect and this, of itself, 
predisposes to disease; a marked anemia often results; 
sleep is disturbed and less refreshing and the child dur- 
ing the sleeping hours does not recuperate as it should. 
The disea-se occurring as it does during the develop- 
mental period of the individual and at a time when the 
pharynx is proportionately very small, is an additional 
and strong reason for early and prompt opei-ation. Any- 
thing interfering with normal development, mental or 
physical, is sure to leave a pei'manent mark. 

Wood states that in a children's hospital of over 300 
children with nose or throat trouble, neai'ly one-half had 
hypertrophied pharyngeal tonsils and that the hyper- 
trophy was the main cause of their trouble. Chronic en- 
largement of the tonsils being so common a condition 
1 and leading to such dire results, would it not be well if 
physicians weio prepared to operate when necessary ? It 
i can generally be done so soon as the diagnosis is made; 
P seldom is anything gained by waiting. If the physician 
postpones operation, many will put it off until many of 
e evil results have been established. We should learn 

operate as quickly, painlessly, and safely as possible. 

d people will then dread it less. When the dire consc- 
iences of nonoperative treatment are fully under- 

id proper treatment will be readily accepted. In 
of the large number of deaths due to diseases of the 



respiratory tract, such diseases being mostly caused by 
bacteria in the inspired air, it becomes imperative that 
we guard well the entrance thereto. In the crusade 
against pulmonary tuberculosis let us not forget to keep 
the throat and nose in as healthy a condition as possible. 



DIGEST OF MEDICAL LITERATURE 



OPHTHALMOLOGY, 

Walter Ij. Pylk 



THE ETIOLOGY AND PATHOLOGY OF CATARACT. 

BY 
WALTER L. PYLE. 

There have been published recently a number of 
studies in the pathology of cataract, together with 
many suggestive inquiries into the general etiology of 
the various forms of this affection. The dependence of 
many cases of altered transparency of the crystalline leus 
on more or less profound constitutional derangements is 
definitely shown and the importance of prompt treat- 
ment of any associate malady is properly emphasized. 
Although marked confidence in the value of general 
prophylaxis is now firmly established, there has been 
little of promise developed in the attempts to devise a 
strictly nonsurgical treatment of senile cataract. Of in- 
terest, however, in this connection are the papers of 
de Wecker, Badal, and Verdereau. There is still much 
to be learned from careful study of the cases of spon- 
taneous resorption occasionally observed. 

E. Zirm (Wiener klinische Wochenschrift, March 23, 
1905), in a recent paper on the nutrition of the lens, dis- 
cusses the origin of different forms of cataract in dis- 
turbances of this nutrition. In order that the lens may 
retain its transparency it is necessary that the nutrient 
fluids which surround it should always be of the same 
density and composition, containing nothing injurious 
to it; and, as it is nourished by endosmosis, it is all im- 
portant that the capsule and the underlying epithelium 
which regulate osmotic changes should preserve their 
integrity. As illustrating injuries seemingly caused by 
increased specific gravity of the fluids he cites the experi- 
ments of Kunde, who produced haziness of the lens in 
frogs by injecting solutions of sodium chlorid or sugar 
into the stomach or under the skin and at the same time 
deprived them of water ; and of Heubdel, who produced 
the same haziness by introducing powdered substances 
into the conjunctival sac and beneath the nictitating 
membrane ; and of Bouchard and Charrin, who had the 
same results from injections of naphthalin into the 
stomach of rabbits. He also quotes Leber as ascribing 
glassblowers' cataract to excessive evaporation from the 
cornea and abnormal loss by perspiration, thus concen- 
trating the aqueous. That it may not be the change in 
density of the fluids but some other simultaneously pro- 
duced condition which is responsible for the cataract, has 
been indicated by other investigators, to whose work 
Zirm refers. Deutschmann found that it required about 
5^ of sugar in the eye media to produce opacities, and 



148 American Mbdicinb] 



DIGEST OF MEDICAL LITERATURE 



rJANUAFY 27, 1906 
LVOL. XI, No. 4 



in a diabetic case in wiiich there was 8 fc in the urine and 
in rabbits to whom enormous quantities of sugar had 
been fed the percentage in the media was far below the 
necessary ofo, the inference being that the cataract of 
glycosuria is not due solely to the sugar in the ocular 
fluids setting up osmotic changes. According to this 
observer, it is influenced by primary necrosis of the lens 
epithelium analogous to that of the kidney epithelium. 
SalfiFner believes the cataract of naphthalin poisoning 
also to be due to injury of the epithelium by a decompo- 
sition product, notwithstanding that Peters finds that in 
the poisoned animal the salts of the aqueous are increased 
from the normal 0.83^ to 0.86/0 or 0.875^. Cataract 
due to damage to the osmotic membrane is illustrated 
by Forster's massage operation. Leber states that the 
subjacent epithelium is injured when the capsule is un- 
hurt. Demaria (Graefe's Archive fiir Ophthalmologie, 
February, 1904) also found experimentally that the pro- 
duction of cataract by massage of the lens is due to lesion of 
the epithelium and diff"usion of the aqueous under the 
capsule with secondary changes. An hour after opera- 
tion there was considerable increase in the weight and 
size of the lens, although there was no visible wound of 
the capsule. Results similar to those from massage are 
caused by poisons, the actinic rays of light, and elec- 
tricity. Zirm refers to the changes supposedly brought 
about by autotoxins from the intestinal canal, pregnant 
uterus, and other organs. Peters holds that nutritive 
disturbances from circulating poisons, etc., are brought 
about by injury to the ciliary epithelium, which regu- 
lates the secretion of the aqueous. Leber (Klinische 
Monatsbliltter fiir Augenheilkunde, March, 1905), on the 
other hand, believes the cataract occurs before the ciliary 
changes. Cataract caused by general diseases, acting 
through their influence on metabolism, has been reported 
by various authors. Vossius believes that struma may 
produce cataract. Bergmeister connects it with gout. 
Syphilis, malaria, typhus, scarlet fever, tetanus, convul- 
sions, leprosy, and ergotism have been reported as causes. 
Zirm does not accept Michel's arteriosclerotic theory or 
the albuminuric theory of Deutschmann. 

In the changes of nutrition, due to senility, gaps 
form in the cortex which become filled with fluid, mak- 
ing what Ammon describes as the "arcus senilis of the 
lens." This is not true cataract, but in 83^ of the cases 
the disease originates in this zone. Hess (Graefe- 
Larmisch Handbuch der gesampten Augenheilkunde, 
second edition) describes three types of senile cataract — 
that due to degenerative processes, especially of the sub- 
capsular epithelium, that due to deposits in cavities, the 
cortex and nucleus appearing normal, and that due to 
intranuclear changes. He believes that disturbance of 
the whole organism is responsible, rather than mechan- 
ical causes. The results of his extensive investigations 
-as to the influence of hypermetropia and astigmatism were 
negative. He thinks with Knapp that the connection 
with vitreous disease is more frequent than has gen- 
erally been supposed. Paul Boemer (Archiv fiir Oph- 
thalmologie, Ix, 2) believes that the lens is remarkably 
independent of nutritive changes, and he states that the 
majority of cases of senile cataract has nothing to do 
with failure of the general health. Osmotic pressure 



may vary greatly without affecting the transparency of 
the lens; in fact, it can be kept clear for months by 
immersion in oil. He ascribes the pathogenesis of senile 
cataract to a cytotoxin. It is possible in the generative 
process of old age that antibodies are set free which 
possess specific affinity for a definite part of the lens 
protoplasm. It is the main function of the secretory 
apparatus of the ciliary body to keep back hurtful sub- 
stances. Only when this function is imperfectly fulfilled 
can cataract develop. This explains why all the old do 
not have cataract. The cause of the injury to the ciliary 
epithelium is still unknown. That the lens protoplasm 
possesses specific qualities diffterent from other proto- 
plasm is shown in its agglutinating rabbit's blood, but 
not the blood of any other animal, in neutralizing the 
toxin of tetanus, but not other toxins, and in counter- 
acting the hemolytic power of human serum toward 
rabbit's, pigeon's, or guineapig's blood. 

Hess explains the various types of congenital cataract 
by disturbances in the separation of the lenticular ves- 
icle from the ectoderm, in consequence of which the fibers 
not being checked by the limiting capsule, exuberate and 
degenerate. Dubs believes that lamellar cataract does 
not form in the first or second year, but that its origin 
is intrauterine. Peters ascribes it to a primary shrink- 
ing, limited to the center of the lens. Leber believes 
this shrinking secondary. Peters does not believe 
rickets a cause of lamellar cataract. He attributes it to 
a toxin which produces the tetany found in associa- 
tion with rickets, this toxin damaging the ciliary 
epithelium. 

In reporting a case of cataract from electric injury, 
Desbrieres and Bargy (Annales d'Oculistique, February, 
1905) suggest as possible modes of origin chemic altera- 
tions, destructive action of the current, alterations of 
circulation, and a shaking up and rearrangement of the 
lens elements as the current passes. 

Weiss (Klinische Monatsbliltter fiir Augenheilkunde, 
September, 1904) reports an interesting case of posterior 
polar cataract following traumatism. A splinter of iron 
perforated the cornea and wounded the iris without 
injuring the anterior capsule, which remained perfectly 
transparent. 

In discussing the pathology of cataract, E. S. Thomp- 
son (Manhattan Eye, Ear, and Throat Hospital, March, 
1905) states that in anterior subcapsular degenerations 
there is a tendency to involvement of the entire lens, 
although progress is often slow. The same thing occurs 
in a short time in cortical degenerations, with the excep- 
tion of congenital lamellar cataract and of senile cataract, 
which begins with narrow radiations extending from 
the periphery, the latter indicating sclerosis rather than 
degeneration. When large, anterior capsular deposits 
from iritis cause, through contraction, wrinkling of the 
capsule and proliferation of the subcapsular epithelium, 
subcapsular opacities may be due to either proliferatioa 
of the subcapsular epithelium or true degeneration of the 
cortex. Cortical opacities may arise from deposits of 
granular material in the interstices left by the shrinking 
of the nucleus. Nuclear changes are almost invariably 
sclerotic. Posterior as well as anterior cortical and cap- 
sular opacities are brought about by plastic exudates. 



Jandary 27, 19061 
Vol. XI, No. 4 J 



DIGEST OF MEDICAL LITERATURE 



/American Medicine 149 



In senile cataract the changes are usually symmetric. 
Traumatic cataract is characterized by the rapidity of 
the degenerative process. Secondary or membranous 
cataract is composed of capsule, lens fibers, proliferated 
epithelium from the anterior capsule, thickened fibrous 
elements from the anterior layer of the vitreous, and 
fibrous tissue from iris exudates. When present, the 
latter makes the needling operation difficult. 

L. de Wecker (Annales d'Oculistique, March, 1905) 
believes that the prevention of cataract can be attained 
only by general hygiene, by attending in particular to 
the free excretion of urea, and to the correction of any 
error of refraction. Dransart claims that by these means 
cases have been reduced half, but it is impossible to 
produce evidence for such statements. De Wecker 
believes the majority of cases occurs in subjects of arthritic 
and arteriosclerotic changes. Doubtless something can 
be done by relief of arteriosclerosis. Some of these 
patients may have intermittent diabetes, consequently 
there should be frequent urinalyses. If cataract consists 
in separation of the lens elements and deposit of fluid in 
the spaces, there is nothing essentially absurd in attempts 
to restore normal conditions or at least prevent further 
progress. With softening or sclerosis a diflterent aspect 
is assumed. Yet even in this case the masses of cortex 
may be absorbed and the nucleus fall out of sight, or 
atrophy of the suspensory fibers may permit dislocation 
of the whole lens. Restorations of vision reported from 
health resorts may be due simply to improvement in 
general health, without special change in the condition 
of the lens. Claims as to the arrest of cataract by treat- 
ment are difficult to maintain on account of its erratic 
behavior without treatment, the disease often remaining 
stationary for years, and then lighting up again. As to 
attempts to restore the integrity of the lens, de Wecker 
is disposed to look favorably on injections of iodid of 
potassium o fc , with acoin 1 ^ , or cocain 2 fc . The injec- 
tions should not be made subconjunctivally merely, but 
deeper into the orbital tissues. He prefers this to bath- 
ing the eyes twice daily in a 1 to 40 solution of the iodid, 
as recommended by Badal. His experiments with an 
extract from the media and internal membranes of the 
eye have been inconclusive. Verdereau (Archives de 
Oftalmologia, October and November, 1904), of Barce- 
lona, reports as a result of numerous injections of potas- 
sium iodid in one case a rise in visual acuity from -^^ to #• 
Augieras (La Clinique Ophtalmologique, August, 
1904) reports a case of spontaneous resorption of a com- 
pletely cataractous lens after iritis, the corrected vision 
= y"n, and another case in which peripheral strife disap- 
peared after several days of physical exercise and very 
low diet, the patient having at the time acute conjunc- 
tivitis. He believes the results in both cases were due 
to good health, regular exercise, and the local inflamma- 
tory process. C. Harms (Klinische Monatsbliitter fiir 
Augenheilkunde, August, 1905) reports a case in which 
remnants of a lens dislocated into the anterior chamber 
were examined in the eyeball, which was enucleated on 
account of the pain of secondary glaucoma. He refers to 
von Hippie's belief that cataract resorption is due to 
obliteration of capsular epithelium, thus giving access of 
atiueous to the interior, and also to Axenfeld's opinion 



that it is the final stage of Morgagnian cataract, inde- 
pendent from the capsular epithelium. Harms believes 
from study of his own case that through liquefaction of 
the lens substance the epithelium is deprived of support, 
and in the course of years is detached by movements of 
the loose capsule. 



REVIEW OP LITERATURE. 

Staining of the Conjunctiva by Protargol. — 

S. Snell (Ophthalmoscope, August 1, 1905) reports two 
cases in one of which the drug had been used nearly two 
years and in the other almost five years. The ocular 
conjunctiva was rendered a dark olive tint and the con- 
junctiva of the lower lid was almost black. In each the 
thickening of the palpebral conjunctiva made each lower 
lid appear somewhat full. He has never seen so decided 
staining from silver nitrate. The cases indicate that 
protargol needs care in its use, the patient keeping him- 
self under close observation, [ii.m.] 

Varicella of the Cornea.— Ocular complications, 
and particularly corneal involvement, being of very rare 
occurrence in chickenpox, H. E. Oppenheimer (Deutsche 
medicinische Wochenschrift, 1905, xxxi. No. 21, 833) 
reports such a case having been observed by him. The 
patient, a girl of 2, was passing through a typic attack 
of the disease and was covered with the dried up 
remains of large numbers of vesicles. On the sixth day 
it was noticed that her left eyelid was inflamed ; it was 
red and edematous and could not be raised spon- 
taneously. When elevated, the ocular conjunctiva 
beneath it was seen to be injected and a number of 
small hemorrhages were seen to be in different parts of 
it. The pupil was myotic, but perfectly rounded ; the 
cornea somewhat hazy, and at the lower, outer part of it 
a small vesicle with a grey floor could be seen. Its 
epithelial covering was somewhat roughened, as strings 
of mucus were attached to it every time the lid was 
raised. By the next day the vesicle had ruptured, a 
superficial ulcer covered with mucoid secretion being 
found in its place. Instillations of atropin, applications 
of hot X'fo boracic acid solution and tjo xeroform oint- 
ment produced prompt healing. The author believes 
this to have been a chickenpox vesicle, scrofulous ulcera- 
tion being excluded by the superficial position of the 
ulcer, the rapidity of recovery and the good general 
health of the patient, [e.l.] 

Radium in Trachoma. — J. C. Beck (Annals of 
Ophthalmology, July, 1905) reports three cases, two of 
which were completely and one partially cured by 
applications of tubes containing radium broraid. The 
least quantity that one should use is 50 mg. of a 10,000 
radioactivity. The stronger the radioactivity the better 
the results, the highest used for therapeutic purposes is 
that of 1,000,000 radioactivity. Radium acts best on 
superficial lesions, particularly on glandular and lym- 
phoid ti.ssue. The hermetically sealed tube is placed in 
contact with the tissue for 10 minutes to 30 minutes 
daily or less often. The writer has not had a single 
burn, but a marked reaction in one case after long 
exposure. Mechanical irritation from contact may be 
mistaken for reaction from the radium, [h.m.] 



INDEX OF LEADING ARTICLES. 

Journal of the American Medical Association, 

Vol. xlvi, No. 3, January 20, 1906. 

" The Theory of Narcosis." Prope.ssou Hans Meyeu. 
"The Breadth of the Profession of Medicine." Jame.s 

H. McBkide. See American Medicine, Vol. x. No. 

4, p. 137. 



150 



AMERICAN MeDICINBJ 



INDEX OF LEADING ARTICLES 



[JANDAKY 27, lOOii 
Vol. XI, No. 4 



" Rhythmic Sounds Produced by the Alimentary Canal." 

W. B. Cannon. 
"Rest in Pulmonary Tuberculosis." J. G. Hilleary. 
" The Value of Hydrotherapy in the Treatment of Epi- 
lepsy." Guy Hinsdai,k. 
"Tent Cottages for Consumptives." E. P'IjETCHER 

Ingalh and John M. Dodson. 
"The Operative Treatment of Fractures." James A. 

Kelly. 
" A Case of Amaurotic Family Idiocy, with a Summary 

of Reported Cases." Mortimer Frank. 
" The Elimination of the Nostrum Traffic, an Evident 

Duty of American Physicians." M. I. Wilbert. 
"The Treatment of Leukorrhea with the Actual Cautery." 

Guy L. Hunner. 

Medical Record, Vol. 69, No. 3, January 20, 1906. 

" Immunization in Tuberculosis, with Especial Reference 
to the Method of Professor von Behring." Karl 
von Ruck. 

"A Few Facts Concerning Cancer of the Stomach." 
Charles N. Down. 

" Digestive Disorders and Abdominal Pain ; From the 
Standpoint of the Surgeon as to Gallbladder, Pan- 
creas and Gastric Adhesions." John F. Erdmann. 

" The Distribution of Mosquitos in the United States as 
Shown by Collections Made at Army Posts, 1904- 
1905." C. S. Ludlow. 

"Observations on the Use of the Rontgen Ray in the 
Treatment of Certain Diseases of the Skin." Fred 
Wise. 

" Earache." Albert Bardes. 

Boston Medical and Surgical Journal, Vol. cliv. 
No. 3, January 18, 1906. 

" Open-air Treatment of Bone Tuberculosis at the Wel- 
lesley Convalescent Home, with a List of 30 Perma- 
nently Cured Cases." E. H. Bradford. 
What is the Relation Between Human and Bovine 
Tuberculosis and How Does it Affect Inmates of 
Public Institutions ? " Theobald Smith. 

" Should the Tuberculous Insane in Hospitals be Segre- 
gated?" O. F. Rogers. 

" What Should be the State Policy Regarding Tubercu- 
losis in Insane Asylums? " Owen Copr. 
' What Special Instructions Regarding Tuberculosis 
Should be Given Institution Nurses and Other Em- 
ployes ? Are Nurses Caring for Cases of Tuberculo- 
sis in Danger of Contracting the Disease?" John 
H. Nichols. 

"The Importance of Early Diagnosis in Cases of Pul- 
monary Tuberculosis." Herbert C. Clapp. 

"The Treatment of Tuberculosis in Public Institutions." 
Wilder Tileston. 

" The Suppression of Tuberculosis in Our Dairy Herds." 
Austin Peters. 

"Day Sanatorium for Consumptives, Parker Hill, Bos- 
ton." David Townsend. 

New York Medical Journal, Vol. Ixxxiii, No. 3, 
January 20, 1906. 
" The Primordial Nature of the Forces Exerted Against 

the Penetration of Bacteria Beneath the Surface of 

the Body." Jonathan Wright. 
" The Maintenance of Asepsis." Daniel H. Craig. 
" Some of the Uses of Pelvic Massage." Joseph Tabek 

Johnson. 
" The Therapeutic and Prognostic Value of Occult 

Hemorrhage in the Stools." J. Dutton Steele. 
" The Sharp"Curet Within the Uterus." Byron Robin- 
son. 
" Rupture of the Symphysis Pubis, with a Report of a 

Case and Description of a Method for its Repair." 

Thomas B. Eastman. 
" The Present Status of Surgical Operations on the 

Insane." Le Roy Broun. 



" Migration of Helminths." Henry Page. 
" Congenital Hernia of the Umbilical Cord, with Report 
of Two Cases." E. W. Meredith. 

The Lancet, Vol. clxx, No. 4298, .lanuary 18, 1906. 

" Aphasia." Byrom Bramwell. 

" Professor A. E. Wright's Method of Treating Tubercu- 
losis." W. Watson Cheyne. 

"A Medley of Surgery." E. E. Goldmann. 

"The Pathology and Bacteriology of Serous and Puru- 
lent Pleural Effusions in Children." J. G. Emanuel. 

" A Case of Poisoning by Nitrobenzol." A. H. H. 
Vizard. 

"Strangulation of an Infantile Umbilical Hernia." 
Philip Turner. 

" Two Cases Illustrating Sciatica of Abdominal Origin : 
Laparotomy." F. W. Forbes-Ross. 

British Medical Journal, No. 2350, January 13, 

1906. 

"Some Unusual Manifestations of Syphilis in the Upper 
Air Passages." Sir Felix Semon. 

"The Reality of Enterospasm and Its Mimicry of Ap- 
pendicitis." Herbert P. Hawkins. 

"Clinical Remarks on Pelvic Appendicitis and the Im- 
portance of Rectal Examination." Geo. E. Arm- 
strong. 

" Diffuse Peritonitis from Perforation of the Appendix : 
Its Diagnosis and Treatment, with a Record of 14 
Cases with 12 Recoveries." Chas. A. Morton. 

" Remarks on Some Functions of the Omentum." 
Rutherford Morison. 

" A Precis of the Conditions under which Lunatics are 
Received in Continental Asylums, with a Special 
Note on Voluntary Boarders." Marcus Wyler. 

Miinchener medicinisclie Woclienschrift, Vol. 
liii, No. 2, .January 9, 1906. 
" Difficult Decanulation." Schmieden. 
"Bier's Congestive Hyperemia in Diseases of the Eye." 

Renner. 
" Investigations Into the Etiology of Syphilis." Siegel. 
" Oversensibility and Quickened Serum Reaction." 

PiKQUET and Schick. 
" Examination of Blood Droplets for Typhoid Bacilli," 

Mueller and Graef. 
" The Influence of Erysipelas on Blood Diseases." Stad- 

LER. 

" The Diagnostic Value of Rontgen Rays and the Use of 
Mercurial Bougies in Diseases of the Esophagus." 
Cahn. 

" Treatment of Diverticula of the Esophagus." Lotheis- 

SEN. 

"Remarks on Cyclodialysis, Based on an Experience of, 

56 Operations." Heine. 
" Flatfoot Diagnosis." Schuemann. 
" The Prevention of Puerperal Fever." Sakadeth. 
" A Urinal for Children." Finkelstein. 

Deutsche medicinische Woclienschrift, Vol. 
xxxii. No. 2, January 11, 1906. 
" Experimental Inoculation of Monkeys with Syphilis; 

Third Communication." Baermann, Halber- 

staedter, and Neisser. 
" The Value of the Progress of Renal Surgery for the 

Practising Physician." Kuettner. 
"Subcutaneous Rupture of the Spleen." Friedheim. 
" A Method to Demonstrate Typhoid Bacilli in Blood." 

CONRADI. 

"The Radium Treatment of Trachoma." .Iacohy. 

" Examinations and Remarks Concerning Old and New 
Balsams." Vieth, Ludwigshafen, and Ehr- 
mann. 

"A Case of Poisoning with Beta-Eucain." Joseph 
Kraus. 

" The Influence of Malarial Fever on Pregnancy, Labor, 
and Puerperium." C. Louros. . 



,."» 



American Medicine 



Havid Riesman 
Ai.tER G. Ellis 
M, B. Hartzell 
nokman b. gwyn 
Helen Murphy 



GEORGE M. GOULD, Editor 



J. Chalmers DaCosta 
H. A. Wilson 
J. Torrance Hugh 
Bernard Kohn 
John W. Churchman 



G. C. C. HOWARD, Managing Editor 



COLLABORATORS 

A. O. J. Kelly 
WiLMER Krusen 
John Knott 
Lawrence Hendek 
A. H. Stewart 



Solomon Solis Cohen 
John Marshall 
J. H. W. Rhein 
J. Coles Brick 
A. L. Benedict 



Charles E. Woodruff 
Walter L. Pylk 
D. Bbaden Kyle 

EUQENE LiNDAUEB 

Alfred Gordon 



PuBLiSMEO Weekly at 1321 Walnut Street Philadelphia by the American-Medicine Puqlishinq Company 



Vol. XI, No. 5. 



FEBRUARY 3, 1906. 



$5.00 Yearly. 



Imbecile inimig-rants were discussed at the recent 
^'(•w York conference on immigration by Robert S. 
Watchorn, commissioner of immigration. He deplored 
the fact that while the law excluded idiots, it did not 
mention the imbeciles or the feeble-minded who were 
equally unfit for citizenship. There is no dividing line 
between these classes, so that borderland cases are ad- 
'' mitted through political influence, whereas they might 
be considered to be idiots. It seems that such fine tech- 
nical distinctions really defeat the purpose of the law. 
The word idiot has a general as well as a technical mean- 
ling and includes the imbeciles and even the feeble- 
minded. The law evidently uses it in this broad sense, 
for it is absurd to think its framers would have thought 
that imbeciles and the feeble-minded were proper kinds 
of immigrants. It was designed to exclude persons who 
would become public burdens, but it is well to inquire 
whether it is not now time to extend its application and 
X) exclude those who are so feeble-minded that they can- 
act be trusted with the franchise even if they are appar- 
ently able to make a living with a pick and shovel, 
trhese almost brainless animals are pouring into the 
iountry at a tremendous rate and will propagate their 
type, which is a healthy normal one, even if lacking in 
ntelligence. It is beginning to be known that educa- 
ion will not make these men more intelligent and that 
re are filling the country with unassimilable men who 
an never become good citizens or ancestors of such. 
)emocracy requires brains. Wherever there is a lack of 
itelligence, there do we find political corruption in 
very form and a perversion of the democratic form of 
overnment. Hordes of Russians can be drilled as 
)Idiers to fight those who are struggling for freedom 
id could be used to destroy our freedom. We seem to 
• laying up trouble for posterity. 

Illiteracy and lack of brains are never treated 

gether in the numerous statistics on the one subject 

the other. A bulletin on illiteracy has recently been 



issued by the Bureau of the Census, and contains some 
interesting data on this subject. The figures show that 
there is a general improvement in the United States, but 
the details are of no significance. The least illiteracy is 
among natives, yet those born of foreign parents are less 
illiterate than those born of native parents, probably 
because the foreigners remain in the cities where schools 
are more numerous and conveniently located. Country 
natives not infrequently are unable to get to school. 
The next class is the foreign white, then come the Jap- 
anese, Chinese, negroes, and Indians. The most inter- 
esting part of the bulletin is a table of European illit- 
eracy, copied from the 1899 report of the United States 
Commissioner of Education. It is known that the 
largest average brains are in the northern part of 
Europe, tlie center being in Scandinavia or thereabouts. 
Of course there are large and small variations every- 
where, but the average brain weight of a nation seems 
to diminish in proportion to its distance from this hypo- 
thetic brain center. This fact has been known a long 
time. 

That intelligence in a general way is due to the 
size of the brain is also well known. Consequently it 
would seem that if people are illiterate in their native 
land, it may be due not so much to lack of opportunity 
as to lack of capacity. This is rather borne out by the 
following table of the number of illiterates per 1,000 in 
the various countries, the numbers increasing In a gen- 
eral way from the brain center outward to the regions 
which are now furnishing our immigrants : 

Sweden and Norway 1.1 Ireland no 

German Empire . . 1.1 Austria 238 

Switzerland .... 3.0 Hungary 281 

Denmark ..... 5.4 Greece 300 



Finland 16.0 

Scotland 35.7 

Netherlands .... 40.0 

France 49 

England 58 

Belgium 128 



Italy 383 

Russia 617 

Spain 681 

Portugal 790 

Servia 860 

Rou mania 890 



152 Amkbican Medicine] 



EDITORIAL COMMENT 



rPEBROABV 3, 1906 

LVOL. XI, No. 5 



Quack remedies in 1816 are well described in a 
book on Hypochondriasis, published about 1820, by Dr. 
George R. Rowe, F.R.C.P. and F.R.C.S. On page 30 
he refers to the use by a patient "of various empiric 
remedies, which are daily offered to the public as infalli- 
ble and innocent in their composition, although they 
contain drugs of the most pernicious nature, and so far 
from being an antidote, become a powerful auxiliary to 
the rapid progress of that disease they are warranted to 
cure." The newspapers of a century ago were far worse 
offenders than they are today, for all the advertisements 
were the boldest kinds of frauds, and moreover the 
venders used the press to accuse each other of dishonesty 
and various misdemeanors. The issues of London 
papers of November, 1805, which contained the accounts 
of Nelson's death and victory at Trafalgar, are said to 
contain quack advertisements which are more interest- 
ing now than the war news : 

Howley's Invaluable Fever Pills. — Being the 
best and safest Medicine ever offered to the Public for 
the certain and speedy cube of feveks, pains in the 
STOMACH, and violent headaches, even when affect- 
ing the Senses. — Two only, at once taking, cured Mr. 
John Sartin, a shoemaker, supposed to be on his death- 
bed, of a violent Fever, of which his wife had died, and 
he never ailed anything for 20 years afterward. Mr. 
Farmer, of Court street, Whitechapel, many years ago, 
was cured by them within two days, of a violent head- 
ache, which affected his senses, and so as to have had 
no return since, of which he hath given a Certificate. 

Human nature has not changed much in a century 
— it does not change in millenniums, for the old Adam is 
still in us all. The present-day frauds differ in style 
from these old ones, as they differed from the medical 
mountebanks of the middle ages and these from the 
ancient witches, but they are all alike in principle and 
will be with us always. As long as there are fools to be 
fooled there will be frauds to fool them. Nevertheless it 
does seem that the evils are less than they were a century 
ago. There is cause for optimism. Indeed, the history 
of quackery does show a steady improvement and we 
need not worry about the future. Though we cannot 
end it, we can keep pounding away to limit its evils. 

•' Preying on the Incurables " is the title of the 
last of the remarkable articles which have appeared in 
Collier^ s Weekly (January 13). This is the sad and really 
ghastly side of the nostrum trade. Dying men will buy 
anything suggested to them as a possible cure, and most 
uncanny advantage is taken by the quacks. Were it 
not for the incurables, indeed it is quite likely that at 
least half the nostrums would be unprofitable. This last 
article is painful reading, but it is sure to do good in 
creating a public conscience. Then the incurable might 



be protected from his own folly, but so long as he is con- 
sidered legitimate prey the miserable business will go on 
as it always has. The drowning man grasps at a straw, 
and there is always a scoundrel ready to sell him one. 
A great deal of these frauds make use of the mails, 
and the Postofflce Department is busily occupied in run- 
ning them down. In time the government will be able 
to check or even destroy this part of the business, but it 
is desirable to have local authorities act, as in the case of 
the notorious quacks prosecuted by the New York 
County Medical Society. A general movement all over 
the country is desirable. The credulity of the victims 
in accepting the wildest kinds of absurdities is the 
astounding part of recent revelations. Someone has 
neglected a duty in failing to enlighten the public, and 
a campaign of education among laymen is an essential 
for a successful fight. 

Are patent medicines dangerous ? is asked by 
the Nulional Druggist in its December issue. The edi- 
torial appears in the New York Commercial, of December 
20, 1905, apparently as a paid advertisement. It is in- 
tended to show that the evils of nostrums are much 
overestimated and bases its argument upon the few re- 
corded deaths it can collect from newspaper clipping 
bureaus. Even including fatalities from carbolic acid 
and similar poisons, it counts up but 292 violent deaths. 
As it estimates 25 daily sales in each of the 40,000 drug 
stores of the country, or 365,000,000 per year, the sudden 
deaths are not of any moment. If they were the rea| 
danger the point would be well taken, but no one eve* 
seems to have accused nostrums of instantly killing tl»B 
buyers. The evil is in the fact that they do no good^ 
but allow the patient to progress to a slow death if he fe 
really very ill. The matter is mentioned merely to ex» 
press regret that the journal should have taken thts 
stand in favor of the nostrum trade. It places the drug- 
gists of the country in the category of quacks instead o! 
passive sellers of what the people demand. The coaiW 
things said of the medical profession are unworthy ^\ 
respectable journalism and we hope will never bt 
repeated. 

Jerome Cochran and His Plan of Sanitary Got- 
erunieut. — An anonymous correspondent, signing him 
self " M. D.," has enclosed an editorial of the MobH 
Register, under date of December 5, furiously attackiof 
American 3Iedicine^s editorial strictures on sanitary gov 
ernment in Alabama. Our unknown friend asks us t* 
reprint the Register''s editorial. There are several point 
of undoubted merit in this assault on our editorial judg 
ment, but we cannot reprint it or make categorical reply 
because another and an authoritative champion of Ala 
bama's sanitary institutions has sent us a communiiii 



Febbitary 3, 1906T 
Vol.. XI, No. 5 J 



EDITORIAL COMMENT 



tAMKRICAN MEDICIJSf* 153 



tion which we feel bound to print, and which covers the 
same ground, with the exception of one important par- 
ticular. Of all the various and voluminous ignorance 
imputed to us by, the Register, one sort would fill these 
editorial rooms with most burning shame. The Register 
asks " Has American Medicine never heard of Dr. Jerome 
Cochran?" Civic pride is usually shocked, and some- 
times angered, that the fame of a distinguished citizen 
has not overspread the world, and often, on the other 
hand, an intelligent community is astonished to learn 
that a fellow-citizen, wholly misunderstood or half- 
appreciated at home, wields a powerful influence far 
beyond the borders of his State and the circle of his 
acquaintance. The reputation of a physician seldom 
travels far ; it is confined, by the nature of his calling, 
to a narrow circle. To have been well known at home 
and abroad while living, and to be familiarly talked 
about ten years after his death, is a very remarkable 
distinction for a physician. The year 1831 includes a 
principal date in the chronology of American medicine, 
for Jerome Cochran was born in that year. Nature is 
not so prodigal of large gifts that one may overlook such 
a man and at the same time pretend to know the history 
of American hygiene. Without a knowledge of Coch- 
ran's life and work, American Medicine would not have 
aimed so severe a criticism at the sanitary institutions 
of Alabama. If Alabama had not had a chance to excel, 
it would have been unfair to distinguish Alabama 
among the four States whose sanitary government we 
criticised at the same time. But Alabama had a superb 
advantage and that advantage was Jerome Cochran. 
The most important of Cochran's achievements was that 
he organized the medical men of his State with extraor- 
dinary thoroughness, making them recognize and pro- 
fess their civic oMfira^tons as coextensive with and insepa- 
rable from their professional duties. Under his leadership 
the medical profession of Alabama became responsible 
for preventive medicine as well as for curative medicine, 
and the people of Alabama, in General Assembly, rati- 
fied this fine conception of medical science as a political 
instrument. What have the people of Alabama done 

I with their legacy from Jerome Cochran? Digged in the 
earth and hidden it — added nothing to it — ceased even 
the enumeration of births, deaths, and causes of deaths 
among the citizens — rejected the coun,sel of a united 
medical profession pledged to serve the public in pre- 

I ventive medicine— lost the best start ever ofitered to an 
American State — slept till the world was a lap and a half 

I ahead, and when prodded into half-awakene.-ss by a rude 

I criticism, mumbled about Jerome Cochran, as if Jerome 
Cochran, ten years dead, could now, as he did in life, 
compensate their inertness. 



The Medical Society of Alabama aud the Sani- 
tary Government of the State.— The same editorial 
which aroused the Mobile Register into a reminiscence of 
Jerome Cochran called forth from Dr. W. H. Sanders a 
letter, which is published in this i&sue. Our objection- 
able editorial said this and no more about Alabama: 
" The State Board of Health of Alabama is a mirage, a 
figment of medical imagination, believed in by its 
sponsors, but of little or no utility to the people of Ala- 
bama." Now the State Board of Health of Alabama is 
the Medical Society of Alabama, and the chairman of 
the Committee on Sanitation is the State health officer. 
Dr. W. H. Sanders is the State health officer by virtue 
of his election by the State Society to the chairmanship 
of a special committee. Dr. Sanders' defense of the State 
Board of Health is therefore a defense of the medical 
profession of Alabama, the sponsors for a scheme of 
sanitary government which, we have said, is a figment 
of medical imagination, having little or no utility. The 
particulars of this arraignment are not included in our 
editorial, but they can he found by reference to former 
editorials in the last volume of American Medicine, and 
can be conveniently verified by reference to Dr. Sanders' 
letter. Dr. Sanders points with great pride to the his- 
tory of Alabama quarantine against yellow fever, but 
on every other matter in the scope of practical hygiene 
he is either silent or else he makes excuse for confessed 
deficiencies, or else he charges other States with equal 
sanitary delinquency. The whole gist of our former 
argument can be briefly reconstructed on Dr. Sanders' 
defense. It is not neces.sary to deny that Alabama quar- 
antine has prevented epidemic yellow fever. The prop- 
osition cannot be proved or disproved. If the exclusion 
of yellow fever were perfect, Alabama (luarantine is, in 
our judgment, excessively rigorous and expensive. No 
rejoinder need be made to the argument that other 
States neglect, as Alabama does, causes of current mor- 
tality and morbidity. But when, in extenuation of 
delinquencies confessed. Dr. Sanders pleads that the 
people of Alabama are not sufficiently enlightened, the 
responsibility is shifted, \ye think, unfairly. 

There are no reports on the vital statistics of 
Alabama as to population, births, deaths, or morbidity. 
There is no effective notification law, or at least no regu- 
lar notification. There is no laboratory of hygiene. 
The vaccination law is inoperative. No systematic 
investigations are made of causes of disease prevalent 
among the people, and very little effort is made to con- 
trol them. Granting Dr. Sanders' statements to be irre- 
futable on every point, the conclusion is irresistible that 
Alabama lacks the essentials of a practical public health 
equipment, and Dr. Sanders says in explanation that 



15 1 Ambkican Mkdicini? 



EDITOEIAL COMMENT 



rFKBRUABY 3, 1906 

LVOL. XI, No. 5 



popular intelligence has not yet grasped their necessity. 
This may be true, but if true, it is only another way of 
saying that the State Medical Society has failed to edu- 
cate the people of Alabama. Is the public mind more 
refractory in that State than elsewhere? or its tutors 
less diligent? Has registration of births and deaths 
ceased because of popular ignorance ? Physicians are 
the registrars, and registration is not forbidden. Why , 
are infectious diseases not notified ? The consent of the 
people is not withheld. Why is there no laboratory of 
hygiene ? The people do not object to being informed 
about the safety or infectiousness of their drinking 
water. They prefer the services of physicians who 
inquire into the causes of sickness and utilize mode rn 
aids in diagnosis. Nearly a quarter of a century ago 
the physicians of Alabama publicly confessed their polit- 
ical obligations, and the Legislature accepted their politi- 
cal leadership in all that concerned public health. The 
Medical Society of Alabama was at that time the strong- 
est professional association in America, and public opin- 
ion in Alabama seemed at that time well enlightened. 
Nowhere has sanitary government had a beginning so 
auspicious. Of those who participated many have passed 
away, but in 1883 they "sat in the aurora of a sunrise that 
might have dimmed all the stars." When and where 
did that ignorance intrude which defined public hygiene 
as beginning and ending in quarantine against yellow 
fever, and transformed Jerome Cochran's virile and vital 
scheme of sanitary go vernm ent into a " mirage, a figment, 
a thing of little or no utility to the people of Alabama." 
Let us repeat that the present status of sanitary govern- 
ment in Alabama might not interest us especially, and 
would not have been distinguished unfavorably if Ala- 
bama had made substantial progress on the unique 
advantage which was hers in 1883, and which she has 
suffered not only to rest, but also to decay. 

Euthanasia still occupies the mind of Dr. Anna 
Hall, of Cincinnati, who has introduced a bill legalizing 
it through Representative Hill, of the Ohio Legislature. 
Considerable indignation was expressed by several legis- 
lators, who considered it a reflection on their intelligence 
to be even called upon to pass upon such an impossible 
proposition. One newspaper has interviewed numerous 
physicians in various cities and recorded a unanimous 
storm of protest, as waste be expected. The president 
of Harvard University has placed himself on record as 
favoring this uncivilized and therefore inhuman measure 
and has brought down upon his head some well-deserved 
scoldings. There is a new phase of the matter which has 
recently been brought out, and that is the chance such a 
law would give to murder undesirable rich relatives who 
are living too long to suit their impecunious and crim- 



inally minded heirs. This of itself would condemn the 
suggestion did it not condemn itself for the many reasons 
we have already mentioned. The surprising part of the 
matter is the fact that intelligent people can take to such 
an unnatural thing. The sacredness of every life from 
the moment of conception to its final natural demise in 
spite of our eflbrts to preserve it, that is the keystone of 
civilization. Destroy it and the whole arch falls. 

Preventable diseases in war were considered by 
the Section on Hygiene and Sanitary Science at the last 
meeting of the American Medical Association, and the 
following resolution was referred to and adopted by the 
House of Delegates. It no doubt expresses the opinion 
of the medical profession of America : 

Whereas, The science of prevention of disease hav- 
ing been long established on a solid scientific basis, it is 
now time that this fact be recognized by the national | 
legislature ; be it 

Resolved, By the American Medical Association, that 
the attention of the people and of their representatives in 
Congress be directed to the fact that no adequate pro- 
vision by law has yet been made to avoid in time of war 
the preventable deaths by disease of the soldiers who 
offer their lives for the preservation of the nation ;' be it 
further 

Resolved, That this association heartily endorses the 
statement of the President of the United States that the 
people have not compelled their representatives to pro- 
vide adequately in advance for the medical system in its 
personnel, its material, its organization, and its physical 
instruments necessary to make that organization effec- 
tive, which alone, if prepared in advance, will obviate 
the trouble which otherwise is certain to come if we have 
a war. (P. 279, Proceedings.) 

These resolutions are impressive, but are given 
renewed interest by recent remarks of the President 
upon the occasion of the presentation of a medal of i 
honor to Captain Church, of the medical department,; 
for conspicuous bravery in the Santiago campaign. It. 
is quite evident that the administration has no patience; 
with those representatives who are deliberately object- 
ing to the passage of the bill which is designed to remedy 
part of the present deplorable defects. It is doubly evi- 
dent that they are acting in a manner which is sure to 
bring upon them the condemnation of the thinking 
people of the country. Mr. Hull, of Iowa, is the chair- 
man of the Military Committee, and we hope that h© 
will be able to convince his colleagues that the people 
are in a serious mood when it comes to a matter of pro- 
tecting the lives of soldiers in war. There may be dif- 
ference of opinion on Statehood and rate regulation 
bills, and matters of politics or statecraft, but in this 
matter of making the army efficient and expandable, 
without collapse, there is or should be complete unan- 
imity. It is too late to begin when war begins ; it must 
be done now, and it is a serious error to delay longer. 
The medical profession has spoken — let the lay press 
voice the demands of the people at once. 



Fbbroary 3, 1«06T 
Vol. XI, No. 5 J 



AMEEICAN NEWS AND NOTES 



[Ambkican Medicisb 155 



AMERICAN NEWS AND NOTES 



GENERAL. 

No Fever in Panama. — Governor Magoon of the 
Panama canal zone says there has not been a case of yel- 
low fever in Panama in 74 clays. The health of the 
canal zone is excellent. 

Accidents on Railroads. — A bulletin issued by the 
Interstate Commerce Commission shows that during the 
months of July, August, and September last 1,053 were 
killed and 10,386 injured among passengers and employes 
of steam roads in the United States. 

Fifteenth Annual Medical Congress. — Interest is 
increasing in the approaching session of the Interna- 
tional Medical Congress, which is to be held in Lisbon, 
April 19 to 26. John H. Musser, of Philadelphia, is 
Chairman of the National Committee, and Ramon Grui- 
teras, of New York City, is the secretary, to whom all 
applications for membership in the congress and com- 
munications regarding papers should be addressed. The 
sailing date of the American party is April 7, hy the 
North Cxerman Lloyd steamship Konig Albert. The 
arrangements are in the hands of Charles Wood Fassett, 
of St. Joseph, to whom applications for reservations 
should be made. 

PiiTdic Health Menaced. — In the course of an 

I official inspection at Boston last week. United States 

Commissioner of Immigration F. P. Sargent expressed 

the opinion that the public health was menaced by the 

existing conditions of immigration, due to the exposure 

j of healthy aliens to aliens that are diseased. He said 

that the only method of dealing witlrthe problem is for 

I the United States to place competent medical inspectors 

\ at the port of embarkation, whose duty it would be to 

( ascertain first of all the physical fitness of the emigrant 

I for entrance Into this country. Such a method not only 
would protect in great measure the American public 
f, from contact with aliens exposed on shipboard to a con- 
tagious disea.se, but it would protect the healthy aliens 
I from contact with such disease. Instead of spending his 
1 time and his money on the long voyage across the 
' Atlantic only to have all his hopes dashed by the depor- 
tation order of a United States official, Mr. Sargent 
pointed out the immigrant would be made to realize that 
, he could not enter this country. 

E. ASTERN STATES. 

No Diphtheria Epidemic at Harvard. — The medi- 
cal visitor of Harvard University states that the cases 
of diphtheria among the students are very mild and 
that there seems little danger of contagion. There are 
K now 18 patients ill with the disease. The first cases ap- 
• peared about ten days ago and there were rumors of 
r contagion. 

I NEW YORK AND VICINITY. 

I Blaze Endangers 80O in Hospital. — Eight hun- 

i dred patients in Bellevue Hospital were endangered by a 
i! fire in the laundry building early Sunday, yet through the 
V quiet and effective work of the hospital fire brigade and 
' the regular firemen, who responded with muffled bells, 

Ky a small number in some of the outlying pavilions 
re awakened. 
PHIIiADELiPHIA, PENNSYLVANIA, ETC. 
Nurses in Public Schools. — Mayor Weaver has ex- 
«sed no opposition to the Board of Education's propo- 
sition to establish a corps of trained nurses to supplement 
; the public school medical inspectors. He had not had 
. time to consider the matter fully, but was averse to sup- 
' I planting the medical inspectors with trained nurses. He 
I was in favor of any practical plan for safeguarding the 
health of pupils, but dods not believe in establishing a 
liospital in connection with every school. 



Disinfecting the Leased House. — The Philadel- 
phia Board of Health offers to disinfect any house on a 
change of tenants. The board is doing the work of 
disinfection with etflciency. The one difficulty is that 
infectious diseases are not reported, and that realty 
owners do not understand the absolute necessity of 
guarding against the transmission of disease from one 
tenant to another by disinfection at each change of lease. 

SOUTHERN STATES. 

Yellow Fever on German Cruiser. — When the 
German cruiser Bremen arrived at the mouth of the Mis- 
sissippi river, on tlie way to New Orleans, a case of yel- 
low fever was reported on board. Doctor Lamb, in charge 
of the quarantine station, ordered the ship detained and 
screened the patient. Orders have been sent to have the 
vessel thoroughly fumigated. She will be detained for 
six days. 

For a Larger Hospital — There was simultaneously 
introduced in the Maryland House and Senate last week 
a bill which, it is claimed, is strongly endorsed by the 
medical profession throughout Maryland. Through its 
passage the LTniversity of Maryland School of Medicine, 
which completes a century of its existence next year, 
hopes to secure an annual appropriation of $50,000 for 
the years 1906 and 1907 for the erection of a handsome 
extension of the University Hospital on West Lombard 
street, which will be like the present hospital in exterior 
appearance, and will include an obstetric clinic, a new 
amphitheater, new isolating and other wards. The 
medical faculty of the university will raise for this pur- 
pose $200,000, and will ask the State to furnish the 
balance. 

WESTERN STATES. 

Measles Stops Regiment Orders were received 

at Fort Logan from the War Department at Washington 
to postpone indefinitely the departure of the Second 
Infantry for the Philippines. The regiment was under 
orders to start for San Francisco on January 24. The 
postponement Wiis necessitated by the breaking out of 
measles and mumps among the soldiers, and they will 
be quarantined at Fort Logan. 

Smallpox Among 500 Insane. — Smallpox has 
broken out in the Central Insane Hospital main build- 
ing, at Jacksonville, 111., where over 500 patients are 
housed. All visitors to the hospital will be prohibited 
from entering the building for the next 30 days. A 
quarantine on the main building will continue for 14 
days. Surgeons will vaccinate tlie entire colony at the 
hospital at once. The hospital is in the care of Dr. E. 
F. Baker, State inspector, who will visit the insane 
patients twice a day to watch the progress of the disease. 



OBITUARIES. 

William H. Harrison, aged 65, January 10, from 
Bright's disease, at his home in Brunner, Texas. He 
was graduated from the Bellevue Hospital Medical Col- 
lege. During the yellow fever epidemic in Louisiana in 
1878, Dr. Harrison gave his services until he himself 
was stricken with the disease. During the Civil war he 
served as assistant surgeon in the Fourth Wisconsin 
Volunteer Cavalry. 

William O. Porter, aged 60, January 30, from 
pneumonia, at his home in Philadelphia. He was grad- 
uated from the University of Pennsylvania in 1868. He 
was former secretary of the Academy of Surgery, former 
recorder of the College of Physicians, a member of 
numerous medical societies, and a surgeon of the Pres- 
byterian and Philadelphia Hospitals for 30 years. 

Berthold B. Pirosh, aged 52, January 25, at his 
home in Chicago, 111. He was graduated from the Uni- 
versity of Konigsburg, and from the Imperial Univer- 
sity, St. Petersburg, Russia, in 1877. He was a member 



156 Amkbican Medicine) 



THE PUBLIC SERVICE 



fPsBBUARY S, 190« 

LvoL. XI, No. 5 



of the Illinois Medical Association, the American Med- 
ical Association, and various German Medical Associa- 
tions. 

J. W. Fugna, aged 71, January 27, at hi