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Charlotte Medical Journal. 


JSiSSy^ Charlotte, N. C, January, 1908. «*%«. 

Table of Contents, Page 51. 


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Literature to physicians. 


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The Charlotte Medical Journal 



No. 1 

State Maintenance for Epileptics. 

By T. P. Satterwhite, M. I)., Louisville, Kentucky. 

The question of making some special pro- 
vision by the State for the care of epileptics 
cannot be too strongly urged. It is gratify- 
ing to note increased interest shown in the 
public care of them. There are at the pres- 
ent time over nineteen States that have made 
provisions for them. The first important 
tiling to do in an effort to establish any 
public charity, is to get people interested in 
it, and appreciate its benefits. The num- 
ber of unfortunates who suffer from this 
disease is estimated at one to every three 
thousand of the inhabitants, and a large 
proportion of these are feeders for various 
eleemosynary institutions. All asylum men 
know that there are a large number of epi- 
leptics in every insane asvltim, which ought 
to be provided for separately. The Colony 
System for epileptics has been clearly dem- 
onstrated. It is a disease that does not 
shorten the duration of life, and the expense 
for maintenance for many years is large. 
Whereas if the proper environment was pro- 
vided for them, these persons could aid very 
materially toward their own support. Is it 
not as much the duty of the State to lighten 
the burden of misery for a class afflicted 
with one of the dreadful diseases that hu- 
manity has to bear, as it is to provide for 
their sustenance and protection from the 
elements. The dietary of the epileptics is 
simpler than the other class of patients, so 
that almost everything in the way of food 
stuffs can be provided by the labor of the 
colonists. Further, colony life opens up to 
them all that is worth living for, — occupa- 
tion, education, amusement and association. 
The members are bound together by a com- 
mon affliction, and each one can feel the 
equal of his associates. These things alone 
have clearly done more for the epileptic 
than medicine can ever hope to do, and 
this herding of epileptics, imbeciles and de- 
mented people, I hope, will soon cease to be 
a blot on our State. The pathological fea- 
tures of the insane and the epileptic are 
different, and the treatment also. A great 
proportion of the epileptics acquire the habit 
before the age of twenty years. The young 
grow up in ignorance, for they are debarred 
from going to school, and it is estimated 
that 10 per cent, of epileptics become in- 
sane when left uncared for. There are a 
large number of adult epileptics who are 
able to work and be self supporting, but 
whose seizures prevent their employment, 
for no one would employ them. Naturally 

a life of this kind closes to them the usual 
avenues for mental and moral development, 
and it is because of this neglect that so many 
epileptics grow up feeble minded and ignor- 
ant, and an easy prey to all of the degener- 
ative tendencies. Cowers, one of the lead- 
ing neurologists, states that heredity is one 
of the most powerful and important causes 
that produces epilepsy, and that there is a 
family history of epilepsy in twenty-seven % 
cases, while other writers place the rate 
much higher. Cannot this sequestration 
prevent, so far as the colony is concerned, 
the propagation of epilepsy. Just contrast 
the deleterious condition of the epileptic 
outside of colony life, with the healthful, 
industrial life of the colony. He is with 
his fellows, no longer a semi-outcast of 
society, is bound to associates by a common 
affliction and has a common purpose with 
them. He appreciates the opportunity for 
occupation, education, treatment and gen- 
eral physical and mental development which 
these institutions offer, Further that the 
State and society may be enlightened by 
the investigation of epilepsy, and to infuse 
such a knowledge as to the nature and pre- 
vention of this disease, an article from the 
xAmericau Medicine on labor as a thera- 
peutic agent, says: "Labor as a therapeutic 
agent in asylums is not a new idea,- and 
there can be no doubt that its value is in- 
sufficiently oppreciated, and if compulsion 
of hardship is not made a means of secur- 
ing it, they should be induced to do some 
work, for nothing can be more certain than 
the fact that idleness, whether enforced or 
chosen, is destructive of both mental and 
physical health. Nothing is more cruel 
and pathogenic than the sickening do- 
nothingism of the patients in many of our 
sanitariums and asylums. The testimony 
of superintendents who have tried this plan 
is unanimous that in the epileptic and in- 
sane labor is a positive therapeutic value. 
Do they not appeal to us all? Incapable of 
self-support outside of colony life, but able 
to assist in supporting themselves under 
colony management. Superintendents of 
insane asylums recognize that there is noth- 
ing in common between the lunatic and the 
epileptic, and our asylums have many of 
them, for they have no other place to go, 
and they are the source of the greatest 
anxiety regarding their management and 
control. Dr. Evans writes: "Many epi- 
leptics become inmates of prison cells, and 
the courts are forced to hold such criminals 
irresponsible. This affliction is not a vice, 

M^ v 1* iflOQ 

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and should not be neglected, so as to thwart 
all efforts at relief." 1 le says in conclusion, 
the victims ought to have legal 

ground lor suit against the community as 
well as those who have charge of the epi- 
Dr. J. VV. Wherry in his experi- 
ment in regard to convulsive seizures of 
epileptics, recorded a tabulated statement 
epileptics from the insane. 
In 1901 he isolated seven cases. Their con- 
vulsive seizures were one hundred and 
eighty-one a mouth. At the end of twelve 
months they numbered seventy. The sec- 
ond year the seizures numbered fifteen. 
The explanation of the improvement was, 
they had the proper care and treatment, 
and it is known and cannot be emphasized 
too clearly, that the commingling- of the 
two classes of disease is the cause of many 
becoming insane. The segregation of epi- 
leptics will be of incalculable value for in- 
tion in phychiatry. This investiga- 
tion is an education for the physician. The 
patients under their care reap the benefits 
of better diagnosis and expert treatment, 
and where he may find opportunities to turn 
to useful account the faculties which the 
has not already impaired, and where 
he may find encouragement in the thought 
that all that science and philanthropy can 
ure him, is applied for his benefit. 
Let us urge, therefore, that common fair- 
ms to demand an equality of care 
of the epileptic as the insane, and which 
can only be secured by State maintenance. 

Malignant Diseases ol the Stomach, 
Diagnosis In Early Stages.* 

By I)r. M. J. Payne, Staunton, Virginia. 
In the diagnosis of malignant diseases of 
the stomach, abdominal surgery has imposed 
upon the internest, the general practitioners, 
new and important duties. First, the diag- 
nosis must be made early, that is, before 
the appearance of a tumor, hemorrhage or 
cachexia. Must be made accurately as to 
locations, whether at the pylorus," lesser 
curvature or cardia, whether localized or 
generalized, and whether complications 
not, Hospital physicians, consult- 
sicians, specialists of stomach dis- 
as a rule, do not see malignant dis- 
• the stomach in the early stage. 
Man) i asea do no1 consull any physician 
until the advance stage, treating themselves 
b) some so called stomach medicine or inert 
mineral water, and receiving no benefit, 
often harm; come to the physician after 
hemorrhage or cachexia have appeared. 
While mam- pass from one physician to 
another, receiving only a hurried examina 
""» and hasi , : ,i,,. onsel of the 

•Read before the Mi f Virginia. 

later symptoms or complications lead the 
physician to examine the stomach. In 
other words delay is made in the diagnosis 
until the classic picture is complete in every 
detail. A diagnosis made after the appear- 
ance of a tumor, hemorrhage and cachexia 
is of no more practical importance to the pa- 
tient than a diagnosis made at the autopsy. 

To my mind much would be gained by 
classing hemorrhage and cachexia as com- 
plications, rather than symptoms, for one 
may be forcibly struck with the importance 
usually ascribed to these two symptoms, 
when listening to long discussions in the 
consulting room, as to the probable benign 
nature of some tumor of the gastric regions 
not yet attended by hemorrhage or cachexia. 
It seems that the average practitioner is 
very reluctant to make a diagnosis of malig- 
nancy of the stomach until hemorrhage and 
cachexia are present. 

In point of frequency the stomach stands 
second to the uterus, and in the male first. 
The male appears also to be affected more 
often than the female. While no age is en- 
tirely exempt, it is more common after forty 
and increases rapidly after fifty. Race does 
not, as formerly thought, appear to confer 
any special immunity. 

The symptoms of all malignant new 
growths of the stomach are substantially 
alike, therefore in the present paper no at- 
tempt will be made to differentiate clinically 
the several forms. While adeno-carcinoma 
is the more frequent form observed, sarcoma 
undoubtedly occurs. In examining the 
patient it will be observed that he is past 
forty — that till the present complaint he has 
been unusually well, and has not had any 
gastric complaint. He has been accustomed 
to eat any and everything, usually taken, 
and digest it. The history may reveal 
hereditary or association with a cancer case. 
Formerly the appetite has been good, now 
it is poor, or entirely lost. Anorexia (with- 
out an assignable cause > is a very impor- 
tant early symptom. There is disgust for 
food, principally meats. Articles of food 
formerly liked are now distasteful, e.g., 
tobacco, wines, liquors, etc., have lost their 
tempting qualities. Coincident with the 
loss of appetite, loss of weight and loss of 
strength out of all proportion to the emacia- 
tion will be observed. Disgust for food is 
so marked that it is with difficulty that 
nourishment is given. On taking food a 
sense of fullness or bloating, amounting 
even to distress, is usually noticed, possibly 
eructations, and some slight nausea. There- 
fore, it is true that the onset is obscure, in- 
definite, the symptoms as related by the 
patient appear to him as trivial, there is no 
strikingly clear condition to account for the 
rapid decline in health, yet the very fact 


that the man is ill of some serious malady 
impresses itself upon the physician. It is 
this very point that demands one's attention. 
This somewhat typical onset is so slightly 
characteristic to the patient and his family 
that malignancy is not at first thought of, 
therefore I wish to emphasize the import- 
ance in just such cases, that the physician 
should think of malignant new growth of 
the stomach, and begin to observe the case 
from this point of view, till satisfied as to 
the proper diagnosis. 

Two symptoms of special importance de- 
mands now some attention . 

First Pain. — At first, or early pain is not 
a prominent symptom. Indeed, it may 
never reach so intense a degree as to war- 
rant the use of opiates. Visceral cancer is 
not as painful as text books lead one to 
think. When present in the early stage it 
is described more as burning, reference be- 
ing made somewhat definitely to the par- 
ticular area of pain. As a rule pain is in- 
dependent to taking food, and is often re- 
lieved by taking hot water, tea, coffee, etc., 
it, however, when attended by vomiting, is 
never relieved by the act of vomiting as in 
ulcerations. A peculiar symptom in some 
cases, and described by the more intelligent, 
is that of a grating sensation, as if the walls 
of the stomach were being rubbed together' 
Pain may at times be felt in the back- 
especially when the lesser curvature is in, 
volved, but is not characteristic. Tender- 
ness over the painful area has in my experi- 
ence occurred in all cases. Nausea at 
irregular intervals appears early, and may 
or may not be attended by vomiting. Vomit- 
ing may be entirely absent throughout the 
entire course of the disease, even to the 
last, as for example: when the pylorus is 
unaffected. However, whe.i present the 
act is frequent, the food often being vomited 
unchanged, and portions of food taken 
many hours previously may be vomited. 
The quantity expelled is often apparently 
greatly in excess of that taken, due to fer- 
mentation or putrefaction. Particles of the 
cancer tissue, blood and pus may likewise 
be found in the substance vomited. Con- 
stipation is the rule, even in those previously 
not so affected. 

( )bserve carefully the weight, preferably 
have the patient weighed in your presence. 
Keep a weight record. 

Direct now that the patient remove the 
clothing, and it will be observed that the 
emaciation is more marked from the hip 
line upward, and that the trunk is more 
affected than the limbs. The subcutaneous 
fat is absorbed, the skin hangs in folds, and 
on pinching up a fold of the skin one may 
observe that the normal elasticity of the 
skin is greatly lessened or lost. The eyes 

are sunken, and the face often portrays an 
anxious, helpless expression. Depression 
of spirit, even to melancholia may be ob- 

Examine now carefully the heart, lungs, 
and kidneys, and if found free of disease, 
a step of great importance in the diagnosis 
is made. Recall, however, that in the late 
stages of malignancy of the stomach albu- 
men may be detected in the urine in large 
quantities; this should, however, not prove 
confusing. Next, and of great importance, 
is the inspection of the upper abdomen, 
taking care to have a good light and plenty 
of time. Observe carefully and compare 
the sides, watch closely for any fullness or 
undue prominence of either side, picture in 
your mind's eye the position of the stomach 
for often the outline of a tumor may be 
observed. Note carefully the left hypo- 
chondrium for any unusual prominence, 
any sudden prominence rising up from the 
surface. Kussmaul describes a peculiar 
relief or mound rising suddenly and promi- 
nently from the level of the abdomen, and 
after a brief time sinking again to a posi- 
tion of rest. This is spoken of as peristalic 
unrest of the stomach. Boas, however, de- 
scribes the phenomena as a tonic contrac- 
tion of the stomach which is localized. If 
the prominence be grasped with the hands 
when at its height a hard contracted mass, 
resembling the uterus, during the pain is 
observed. To this Boas applies the name 
— gastric rigidity. Fifty years ago Cruveil- 
hier described this sign, and emphasized it 
as an early major diagnostic point. Pain 
and gurgling may attend the contraction. 
Gastric rigidity indicates an obstruction to 
the pyloric outlet. If a tumor be present it 
becomes more prominent during this con- 

By auscultation of the gastric area, de- 
tect the presence of any new sound, gurg- 
ling or splashing, as a further evidence of 
the pyloric obstruction. 

Determine now by palpation and percus- 
sion the area of the liver and spleen, observe 
if present any tender points and tender area, 
likewise observe the association of tender 
points and painful area. In palpating it is 
preferable first to have the stomach empty, 
and if possible determine the stomach area: 
may indicate this by pencil mark. Now 
distend the stomach and define borders as 
accurately as possible. Use preferably gas 
distentions. Observe whether the stomach 
is dilated or contracted, and determine if 
there is displacement of the viscus. In all 
cases of pyloric obstruction the stomach is 
actually dilated at first — however, in cancer 
of thecardia, lesser curvature, and aesopha- 
gus the viscns may be actually contracted, 
that is, after infiltration of the stomach 


walls. Determine now the digestive effici- 
ency, that is, whether or not the food is 

I within the normal time. It" the 

stomach contains food after seven hours 

inefficient digestive functions. Like- 

:: there is motor insufficiency. 

nly practical way t determine this 

is by stomach washing, the technic of which 

I enter into this paper. However, 

if particles of food be vomited, or removed 

by the stomach washing, from eight to 

hours after eating, both digestive 

and motor functions are insufficient. 

Let the stomach contents be tested now 
For Free or uncombined hydrochloric acid. 
This test is now regarded as less positive 
than formerly. The free acid may be pres- 
ent in cancer, I rarely I and absent in con- 
ditions other than cancer. The absence of 
free hydrochloric acid with the presence of 
lactic acid and the ( >ppler bacillus is held 
to lie more indicative of malignancy than 
tin- simple absence of free hydrochloric acid. 
If found that lactic acid is being generated 
in large c\uantities this alone is more conf 
elusive. I Found in about 83 per cent, o- 
all cases. The absence of hydrochloric 
acid and the presence of lactic acid is a 
condition when found early in the process 
of cancer of the stomach is of great import- 
ance, as will be presently understood. If 
the diagnosis is yet delayed the appearance 
of a tumor will admit of no further doubt 
as to the diagnosis, but all must now accept 
the statement that the early stage has passed. 
There is but little practical benefit to the 
patient to advise operative interference after 
the tumor i> found. I was never more forci- 
bly struck with the importance of this, than 
on recently discovering cancer of the stom- 
ach with a tumor, in a patient at his first 
visit to my office. I advised operation, to 
which he readily assented, and on opening 
th.- abdomen the entire stomach wall was 
seen t<» he involved, and the condition of 
affaii - so extensh e a- to render any radical 
treatment not only useless but impracticable. 
It is li!. 3S to advise operative in- 

terference after tin- advent <>f hemorrhage, 
as '.lie appearance of this symptom ra my 
ence i> shortly followed by death. 
To advise operative procedure after cachexia 
has appeared is only to hasten the inevit- 
able. I mal i these sj mptoms 
only to emphasize that the usual classic 
symptoms enumerated in the texl books are 
indicative only of the late — the hopeless 

In hope of stimulating tin- efforts of prac 
titioners, not the specialist, 1 wish now to 
add thai should a patient past forty come 
Milt you, and relate that he has been 
well till the present illness, that in obtain- 
in., the history you hud an indefinite onset, 

a loss of appetite, a dis-ust for food, a dis- 
taste for meats, tobacco and liquor, great 
emaciation, and lost strength, that both the 
digestive and motor functions of the stom- 
ach are insufficient, that nausea, constipa- 
tion and irregular hrexplainable vomiting 
are present, that he complains of burning 
or indistinct pain unassociated with taking 
food, and you find on examination a tender 
point referable to the area of the pain, that 
on distending the stomach there is no mark- 
ed dilatation, that the gastric condition is 
growing steadily worse, the heart, lungs 
and kidnevs are found to be normal, and 
yet the patient appears as if he is a victim 
of some serious malady. 1 claim now that 
if ulceration, chronic gastritis and amyloid 
degeneration be excluded, a diagnosis of 
malignant disease of the stomach should 
be made. 

Exclude ulcer by recalling that both the 
digestive and motor functions are normal, 
or even increased, that is digestion goes on 
more rapidly — the food is digested and the 
stomach empty within two hours. Free 
hydrochloric acid is normal or in excess. 
Pain is greater, more acute, and hemor- 
rhages which is often alarming, recurs less 
frequently than in cancer, and improvement 
shortly takes place. Lost appetite does not 
occur with such frequency as in cancer, and 
the weight and strength are likewise not so 
markedly affected. 

Kxclude chronic gastritis, and only the 
graver forms are apt to be confusing, by the 
fact that the absence of free hydrochloric 
acid is early noted in cancer, and very late 
in chronic gastritis. That an inhibition of, 
or an inefficient digestive function appears 
early in carcinoma and late in chronic 
gastritis. Chronic gastritis never leads to 
complete loss of digestive functions, the re- 
verse being true in malignant disease of the 
stomach. There is never cardialgia, or 
hemorrhage, never distinct or tender points 
in gastritis, the area of tenderness being 
diffused. In chronic gastritis the vomit or 
stomach washings show large quantities of 
mucus. The history of long standing dys- 
pepsia, the absence of lactic acid and the 
Oppler bacillus, and the less striking blood 
changes are likewise indicative of chronic 

Exclude amyloid degeneration of the 
mucus membrane, (rare) by the fact that it 
is always secondary to tuberculosis, syphilis 
or prolonged suppuration. 

further, recall that malignant disease of 
the stomach does not pursue an extended 
course, lor a case existing more than a year 
or a \ear ami a half may safely be classed 
as non-malignant. 1 have not made refer- 
ence to any metastalic changes in the liver, 
to glandular enlargement- either of the left 


supra-clavicular glands, or the peri or para 
umbilical glands, or to ascites, for any or 
all of these symptoms are indicative of the 
late stage. 

While little may be promised except a 
somewhat extended life in the early stage, 
all operative work in the later stage but 
hastens the inevitable end. As a matter of 
interest and importance, likewise to stimu- 
late early diagnosis, a partial gastrectomy, 
though showing a slightly higher immediate 
death rate, is attended in those cases recov- 
ering by a somewhat longer period of life, 
than the more commonly practiced gastro- 

Gangrenous Kidney. Transperitoneal 
Nephrectomy; Recovery. 

By Joseph Graham, M. D., and E. A. Abernathy, 
M. D., Durham, N. C. 

( )ne is rarely justified in making report 
of a single case, but as few men have the 
privilege of seeing a large number of these 
cases our conclusions must be made from 
individual reports. 

Report of Dr. E. A. Abernathy. 

Ula L. : Thirteen years old. Birth normal . 
Childhood without special incident. No 
disease bearing on condition under consid- 

Present History. — About one year ago 
patient was brought to me suffering with 
what 1 thought to be the beginning of men- 
struation. Complained of headaches, back- 
aches, and indefinitely located pains in the 
"stomach." These "spells" came on at 
periods about four weeks apart and lasted 
several days, Since the present conditions 
have developed the mother says there were 
pains that might have been referred to the 
kidneys. 1 do not remember anything that 
led me to suspect kidney involvement. As 
the child was well developed and approach- 
ing the age when menstruation should be- 
gin I diagnosticated the trouble as an effort 
to establish this function. Iron, arsenic 
and manganese, together with proper hy- 
gienic measures were prescribed. This 
treatment was continued over a period of 
months and the menstrual function with 
some irregularities was established and I 
lost sight of the patient. 

On June 3, 1907, was called to see her. 
Learned that four days before while in ap- 
parent good health, she had, when arising 
in the morning, complained of pain in right 
side of abdomen just above crest of ileum. 
This pain had become worse and had grad- 
ually extended over most of right abdominal 

( )n examination: Patient lying on back 
with right thigh flexed; expression indicat- 
ing severe pain. Temperature 1<>4,- pulse 

about 140, running and of poor volume. 
Muscles on right side of abdomen rigid; 
entire right side of abdomen tender with 
marked tenderness over McBurney's point. 
An area of dullness around region of ap- 
pendix several inches across. Bowels had 
been thoroughly moved before I saw patient. 
Kidneys, as far as I could learn, were do- 
ing their work normally. No examination 
of urine was made. 

A diagnosis of acute appendicitis with 
rupture was made, and owing to the appar- 
ent desperate condition of the patient she 
was immediately sent to the Watts Hospital 
at Durham, a distance of twenty miles, 
where she was placed in the hands of Dr. 
Joseph Graham. 

On July 13th the patient was returned to 
my care and at this writing, July 30, 1907, 
her wounds have so nicely progressed that 
her mother is now dressing them. The 
patient is in better health than she has en- 
joyed in the past year, eating what she 
wants, going where she pleases, suffering 
no pain and apparently not inconvenienced 
by the loss of her right kidney. 
Condition on admission to Watts Hospital: 

Well developed girl. Age 13. Ula L. 
Facial expression shows great pain. 

History. — Four days before developed 
sudden pain in right iliac fossa near um- 
bilicus. Pain gradually grew worse and 
was followed by nausea and vomiting. Pain 
was localized in right iliac, region. Pain 
was much relieved during night of second 
day but returned on the third day and was 
more severe and continuous; followed by 
return of nausea and vomiting. The vomit- 
ing was repeated after admission to the 
hospital, No movement of the bowels for 
two days. Purgatives had been repeatedly 
administered by the family before calling 
Dr. Abernathy. Nothing could be elicited 
as to previous history, as patient was suffer- 
ing extremely and father knew little of her 

Examination. — Temperature 104, pulse 
146, respiration 26-30. Patient located pain 
directly over McBurney's point. Palpation 
reveals marked rigidity of entire right side 
of abdomen and some slight general tender- 
ness more pronounced over McBurney's 
point. No tenderness in lumbar region or 
over gall bladder. Percussion revealed an 
area of dullness in right iliac. No irrita- 
bility of bladder, specimen of urine obtain- 
ed by catheter revealed normal Sp- Gr. 
and no albumen. Leucocyte count was not 
made. Rectal examination reveals tender- 
ness in right iliac. 

Eiagnosis. — Appendicitis, Perforation, 

Operation. — Right rectus ( Deaver) in- 


i >n opening abdomen Found omentum 
adherent in right iliac Fossa to colon and 
parietal peritoneum. Working carefully 
through a coffer dam of gauze a perfectly 
normal appendix was found and removed. 
Then sought For the trouble causing ad- 

Pelvic organs normal. Right kidney 
could not be found, carried finger up and 
palpated gall bladder, which was appar- 
ently normal. As finger came away from 
gall bladder a hard, slightly movable mass 
was delected. Enlarged incision and separ- 
ated omentum from colon, packed colon to 
inner side of wound. Then found a hard 
mass behind the mesecolon, the shape of 
the kidney, but approximately twice as 
large. Carefully protecting the abdominal 
contents with gauze diaphragms, an incis- 
ion was made through the outer edge of 
mesecolon. A black, enlarged kidney came 
into view. Deciding to do a nephrectomy, 
we elevated the kidney and found the pelvis 
of the kidney and upper end of ureter to be 
distended with fluid. Expecting pus, care- 
fully protected and then ligated pedicle and 
clamped between kidney and ligature. Then 
cut between clamp and ligature, dropping 
the ligated stump of pedicle and lifting out 
the kidney. As the pedicle dropped back 
it bled profusely. The ligature had cut the 
pedicle. Retied the artery and hemorrhage 
was completely controlled. There was a 
twist in the ureter a few inches below liga- 
ture, but no calculus. Then packed the 
cavity with gauze, which was covered over 
with the mesecolon and the incision in 
mesecolon sutured with catgut. Removed 
gauze protective*, adjusted intestines and 
closed abdomen without drainage. Then 
made incision in lumbar region and brought 
out end of gauze which had been previously 
packed in cavity for drainage. I.'atient was 
considerably shocked but promptly rallied. 

Examination of removed kidney revealed 
a very much enlarged organ, very black in 
color. Incision revealed no pus or stone. 
The kidney was friable and could be broken 
and torn with the fingers by very slight 

Post operative History. — With the excep- 
tion of slight mural abscess recovery was 
uneventful. The girl soon rallied from the 
shock. Temperature and pulse returned to 
normal. No nausea, vomiting or obstruc- 
tive symptoms. Daily examination of urine 
showed quantity above the average 

ely low sp. gr. and at no' time did 
examination reveal albumen, blood or casts. 
She had no headache and no disturbance 
of vision. 

November 1, 1907. The patient is ap- 
parently in perfect health. 

For successful issue in this case I am 

very much indebted to Dr. C. A. Adams, 
who gave very able assistance, and to Dr. 
Will Holt, who administered the ether so 
successfully that we were able to finish this 
Ion.-, tedious operation with a living patient, 
although she went on the table in a desper- 
ate condition. 

Strangulated Inyuinal Hernia in Infants 
with Report of a Case. 

By John Egerton Cannaday, M. I)., Hansford, W. 
Va., Surgeon-in-charge, Sheltering Arms Hospital. 

As compared with its frequency in adults, 
strangulated hernia is unusual in infants, 
the laxity of tissues combined with the ab- 
sence of many of the usual exciting causes 
tending to prevent it. So rare is it that not 
one-half of one per cent, of the cases of 
hernia occurring in infants are strangulated. 
However, when it does occur the lack of 
resistance in the subject renders the indicat 
tions for surgical relief even more insisten- 
than when this accident happens to the 
adult. Continental surgeons, especially 
those of England and Scotland, operate 
rather freely on hernia occurring in infants, 
in this country the persistent use of a truss 
for several years is thought well of. If that 
fails to effect a cure, then the radical oper- 
ation should be resorted to. The infant, 
like the aged and infirm, is in many par- 
ticulars an unsatisfactory subject for surgi- 
cal intervention. In accordance with the 
rule of frequency which obtains with adults, 
about three males are afflicted to one female. 
The abnormally large inguinal opening in 
the infant is usually of congenital origin, 
unlike the acquired condition of the aged. 

A nearby loop of intestine becomes crowd- 
ed into the sac; with the lessening of the 
pressure which forced the bowel down, the 
dilated hernial ring contracts and grasps 
the bowel; the imprisoned intestine is irre- 
ducible and cannot free itself; there is a 
stasis of the fecal current and interference 
with the circulation (producing in mild 
cases venous congestion and in severe cases 
absolute cessation of circulation). The 
ultimate result of strangulation is gangrene, 
the rapidity of development varying with 
the conditions present. The vessel anasto- 
moses are few, the fecal content decomposes 
easily, and bacterial invasion of the sac is 
rapid. The intestine becomes friable; gan- 
grene begins in small areas where the circu- 
lation is poorest; these discrete patches later 
become confluent. Considerable disturb- 
ance takes place in the loop leading to the 
hernia; putrefaction of the stagnant con- 
tents occurs with the resultant gas disten- 
sion; reversed peristalsis and other disturb- 
ances along with peritonitis. Distension 
may be so great as to obliterate the liver 
and splenic dullness. 


In the symptomatology of strangulated 
hernia we have three symptom groups ar- 
ranged from the point of time in the order 
named; strangulation shock, intestinal ob- 
struction, and sepsis. Strangulation shock 
is as distinct an entity as that produced by 
torsion or compression of the testicle. The 
symptoms comprise nausea, vomiting, small 
thready pulse, pallor of the skin and mu- 
cous membranes, cold perspiration and other 
disturbances of the general condition. The 
intestinal obstruction produces meteorism 
varying in accordance with the high or low 
constriction of the gut, the vomitus becomes 
partly oj wholly fecal in character. The 
higher the obstruction the earlier the vomit- 
ing comes on. Sepsis brings about restless- 
ness, lack of appetite, nausea, peritonitis 
of gradual or sudden onset; a general in- 
toxication from the gangrenous or suppura- 
tive condition of the sac may intervene. 
When peritonitis develops suddenly from 
perforation or some other pathological acci- 
dent the pain is violent and localized in the 
beginning, later spreading over the entire 
abdomen. The symptoms common to con- 
tinued and increasing sepsis and intestinal 
obstruction continue and grow worse. Oli- 
guria and even anuris may come on as a 
result of the diminished amount of water in 
the body. 

The diagnosis is based on the history and 
the symptoms. The hernia usually feels 
firmer than before and is often sensitive to 
the touch. An irreducible mass is present 
which extends into tlfe abdominal cavity. 
It may have a certain amount of lateral 
motion, but up and down motion will be 
very limited. At times even when the vital- 
ity of the gut is endangered the symptoms 
may be so atypical and slight as to make 
the diagnosis one of doubt. On the other 
hand, the strangulation of a small omental 
hernia may occasion extreme symptoms. 
At the moment of strangulation there is a 
sharp pain and the hernial mass is increased 
in size. An accurate history is of much 
importance in making the diagnosis. There 
is often a bowel movement from the portion 
below the hernia, soon after the obstruction 
takes place. After the strangulation, cough- 
ing and straining do not influence the ten- 
sion . 

When left to itself the prognosis is so 
grave that recovery would constitute a sur- 
gical curiosity. At times strangulation shock 
alone is of sufficient severity to kill the pa- 
tient; pneumonia, inanition, prolonged sup- 
puration or other inter-current trouble may 
cause a fatal ending. 

The treatment in most cases is undoubt- 
edly and unquestionably surgical so long 
as the patient is not moribund. When the 
patient is seen early after the symptoms of 

strangulation have made their appearance, 
and when the onset has not been acute, 
taxis should be resorted to, and in event of 
failure the hernial sac should be opened at 
once. Taxis is thought by many to be more 
especially indicated in the very young who 
are hard to keep clean, and in the aged and 
infirm who do not bear operation well. 
Taxis may waste valuable time, and may 
bring about the reduction of hernia en bloc 
or bowel that has lost its viability. Violent 
manipulations may cause tearing of the 
intestine. Before resorting to taxis the stom- 
ach and lower bowel should be irrigated and 
emptied, the urine should be drawn, mus- 
cular relaxation obtained by appropriate 
posturing and the use of an anesthetic, and 
the hernia should be elevated so as to be 
the highest part of the body. The fluid 
contained in the sac when opened is an ex- 
cellent indicator of the condition of the in- 
testine. If the fluid is ill smelling or con- 
tains flakes of lymph, the bowel is very 
likely to be in bad condition. In attempt- 
ing to make the decision as to whether a 
piece of gut is viable or not, the sense of 
touch may give more information than that 
of sight. The lifeless gut is flaccid and has 
the feel of moist blotting paper. Gray brown 
spots are indicative of gangrene. Resection 
and even the formation of an artificial anus 
will often have to be resorted to. When 
there has been much infection the radical 
operation should be omitted and the wound 
packed with gauze. In case of doubt sut- 
ures can be placed and left loose to be tied 
later. When the radical operation is re- 
sorted to it is usually best to make use of 
the more simple and time saving methods. 
I do not believe that the transplantation of 
the cord has any particular merit to com- 
mend it. Connell and Ferguson are quite 
certain that it predisposes to epididymitis 
or other inflammatory lesions. Operation 
infection should be very rare when a care- 
ful rubber glove technic is followed. After 
ligating the neck of the sac I often carry 
the ends of the suture upward between the 
parietal peritoneum and rectus muscle, and 
secure the neck of the sac in a higher posi- 
tion so as to obliterate the former funnel - 
like depression existing at the point of oc- 
currence of the hernia. After dealing with 
the sac the hernial opening is closed by the 
introduction of sutures of thirty day chromic 
catgut. The idea suggested by Czerny and 
later elaborated by Ochsner, that 'if the ring 
is denuded of its lining before being closed' 
union will be assured and recurrences rare, 
should be one of the basic principles of sur- 
gery of this part of the body. The co'-d is 
not moved from its normal position, and 
the superficial is sutured over it with a run- 
ning suture of plain catgut. The edges of 


the skin wound are approximated with the 
usual suture of silk or linen thread. 

The operation, as we know it, for the 
radical cure of hernia was first performed 
by Czerny in 1877. The mortality of oper- 
ations for the radical cure of hernia in skill- 
ed hands is from 1-2 of 1 to 1 percent. The 
ity of strangulated cases for many 
reasons will always he high. 

1 will report the following case: The 
patient was a three months old male baby 
referred by Dr. II. S. Reger of Macdonald, 
\V. Va. The child developed a complete 
inguinal hernia soon after birth. This was 
easily reducible at first, but later difficulty 
was experienced in returning the bowel to 
the abdominal cavity. The evening before 
the patient was brought to the hospital 
symptoms of strangulation came on. At- 
tempts were made to reduce the tumor by 
taxis, first without and later with chloro- 
form anaesrhesia, but unsuccessfully. As 
mdition of the child was becoming 
serious it was brought to the Sheltering 
Arms Hospital the next morning and oper- 
ated on immediately. The child was weak 
and considerably shocked. For this reason 
it was deemed advisable to make use of 
local anaesthesia. A sterile 2 per cent. 
solution of beta-eucaine was used. The 
customary method of anaesthetizing the 
nerves, supplying the pans involved and 
also the line of incision was followed. I at 
once dissected the structures down to the 
constriction, opened the sac, enlarged the 
rin-, and as the imprisoned loop of gul 
seemed viable, returned the strangulated 
intestine to the abdomen. I then closed 
the hernial ring with chromicized catgut. 
I taring the course of the operation the parts 
were handled as gently as possible: but little 
shock was manifested and the baby slept 
during the greater part of the time. To 
prevent wound contamination a dressing 
composed of a lew fibres of cotton and some 
flexible collodion was used. The baby 
rallied promptly and in a few hours was 
nursing at its mother's breast. The course 
of convalesi ence was une\ entful and so far, 
six months afterwards, there has been no 
return of the hernia. 

Tosumiu irize I would note the infrequent 
bui occasional occurrence oi strangulated 
hernia in infants. The ease of a reason 
able Certainty in the diagnosis of this con- 
dition. The dangers of laxis by reason of 
ilitj of the structures involved. The 
'dangers ol operations in infants have per 
haps been <■', erestimated. By proper pre 
caution an.! care the risk- of posl operative 
infection can be largely eliminated. The 
shock incident to anaesthesia and prolonged 
manipulation can be avoided l>v the proper 
use of a sterile and practically nun toxic 

anaesthetic and by rapid and careful work. 

Hemorrhagic Malarial Fever: Report oi 

By !•'. A. Webb, M. D., Calvert, Alabama. 

As the title indicates, the purpose of this 
paper is to present the subject in a clinical 
way, giving a practical experience, rather 
than the natural history, aetiology and pa- 
thology of the disease. 

My first experience with this fever was a 
personal one. After an exposure to malaria 
for two years in the river bottom lauds of 
the Tombigbee river, I was attacked late 
one evening in October, 1885, with a chill. 
Language fails to convey the feeling of 
prostration and aching of every part of the 
body I suffered from. The next morning 
at 8 or 9 o'clock I had my second chill, 
accompanied with hsematuria. I was prac- 
tically unconscious and delerious for the 
greater part of the time. My attending 
physician, Dr. Taylor, having given up all 
hope of my recovery, Dr. Y. P. Gaines, of 
Mobile, was called in consultation. By 
heroic treatment they pulled me through. 
During convalescence it was urged by Dr. 
Patsky (a Major Surgeon in the V. S. 
Army), that sweet milk in twenty minim 
doses be given hypodermatic ally, every 
three hours, to increase the red corpuscles 
of the blood, as my anemia at that time was 
very pronounced. Only two of the milk 
injections were given, resulting in abscess 
and blood poisoning, but as one of my good 
friends remarked afterwards, I recovered 
"in spite of the doctors." 

By way of comment, I would not advise 
or advocate the method of my scientific and 
learned physician in the treatment of 
anemia, or to increase the red corpuscles. 

The second case that came under my ob- 
servation was that of a young man, L. B., 
aged 25 years. This young man had been 
exposed in a logging camp known as "Bull 
Pen" in the river bottoms, and here he cou- 
tractdd malaria. He was brought to Cal- 
vert for treatment . I saw him at 3 a. in. 
The history given was one of malaria, and 
had been sick for a week. His entire body 
was intensely jaundiced, had been, and 
was still vomiting quantities of matter that 
resembled black vomit more than anything 
else,' was passing bloody urine, also hemor- 
rhage from the bowels. The vomiting was 
uncontrollable, also the hemorrhages, and 
in a few hours my patient was a dead man. 
This case we might well class "Malaria 
Hemorrhagica bulminans." Xo medica- 
tion seemed to have the least effect, either 
to relieve or stay the progress of the disease. 

My third case was C. P.. 11., male, white, 
aged 30 years. This gentleman had been 


exposed to malaria for a period of several 
years in the river bottoms. In this case, 
prostration, nausea and hematuria were the 
most pronounced clinical symptoms. After 
quite a severe illness of two weeks he made 
a good recovery. 

My next case was Mrs. B. S., white, 
aged 25, mother of three children. This 
woman gave a history of exposure of some 
months to malaria near the river bottoms, 
culminating in the present attack of malarial 
liEematuria. In this case also the extreme 
prostrations bordering on collapse, nausea, 
and bloody urine were the symptoms pres- 
ent. After a ten days illness she made a 
good recovery. 

My next case was with Mr. G. D. K., 
aged 50 years, white. This gentleman had 
been exposed for years to malaria, spending 
a greater part of his time in the river bot- 
toms. When called to see him obtained 
the following history: Had had a chill on 
Wednesday night at his camp on the bank 
of the river — came out next day to his place 
in the pine woods. Thursday morning had 
another chill, followed by hsematuria. It 
was then that I was sent for. Saturday he 
had another chill, also another on Sunday, 
each chill attended by severe prostration, 
hemorrhage and vomiting. After a critical 
illness of four weeks he made a good re- 

It has been my observation that these 
cases occur in the months of September or 
( )ctober, after a prolonged exposure and 
repeated attacks of malaria. 

All cases present a clinical picture of 
prostration, more or less jaundice, nausea, 
hemorrhage, either from the bowels, kidneys 
or stomach, also pronounced anemia. 

Treatment. — This can be summed up as 
supporting, eliminating, expectant, and 
eternal vigilance. The first indication is 
to relieve the utter prostration, aching, 
nausea and hemorrhage. The only drug 
that can be depended upon is morphine 
and atropine — this given hypoderma'tically, 
p. r. n., until these symptoms are under 
control. For elimination, calomel and soda, 
followed by a saline. To act on the kid- 
neys, laxative lithia. To stimulate and 
produce diaphoresis, the hot mustard foot 
bath, the hot corn pack, or the hot air bath. 
As an antidote for the malarial poisoning, 
quinine per orum, rectum, endermically or 
hypodermically. Hot saline enemas will 
be found efficacious to combat shock and 
to stimulate the kidneys and act on the 

I would warn you against the use of any 
of the coal tar preparations. Pilocarpin is 
also a dangerous drug. It is true they will 
produce profuse sweating, but owing to the 
great prostration, and fear of collapse, they 

are dangerous. Tr. chloride of iron, also 
arsenic, have served me well. Adrenalin 
has also suggested itself as possibly a valu- 
able therapeutic agent, but as yet I have 
not tested it in any case. 

And last, but not least, eternal vigilance 
is required — and the expectant plan to be 
followed — if we hope to combat this disease 
with any degree of success. 

The use of quinine is a much debated 
question. From my own experience, when 
given with judgment, it is an important 
therapeutic agent. 

Some Clinical and Practical Points about 
the Prostatatiker and Prostatectomy.! 

By Robert C. Bryan, M. D., Professor Descriptive 
Anatomy and Genito-Urinary Surgery University 
College of Medicine, Richmond, Va., Visiting 
Surgeon to Virginia Hospital, etc. 

Since last appearing before the Medical 
Society of Virginia the writer has had under 
observation some sixteen cases of urinary 
obstruction in men, between the ages of 53 
and 85, due to enlargement of the prostate 

And as my title calls for clinical and 
practical points for relief of this condition, 
the subjects of histology, pathology and 
diagnosis will be only briefly considered. 
As to the physiology, however, we must 
bear in mind that the prostate gland is un- 
like other secreting, constantly elaborating 
glands of the body, in that its removal has 
no appreciable effect upon the balance 
wheel of vital centres, and further, that its 
secretion is destined- for a periodic expul- 
sion, and not to influence, by its absorption, 
the economy and nervous adjustment of the 
body. These two factors are in marked 
contrast with the physiological duties of 
other glands found in the body. Again, 
the prostate is really outside of the body- 
as is, indeed, the remainder of the geuito, 
urinary tract. The only organs of conse- 
quence with which it comes into an anato- 
mical intimacy are the terminal reservoirs 
of the urinary and alimentary canals, both 
of which by virtue of location, ( being extra- 
peritoneal) bony encasement, tnobilitjr and 
generous vascularity, are peculiarly for- 
tunate and immune to traumatism and the 
mechanical insults incident to daily life. 

With its base applied against the anterior 
wall of the rectum and held there by that 
highly developed muscular plane, the recto- 
urethralis; its apex implanted against the 
posterior layer of the firm triangular liga- 
ment; its under surface resting upon the 
unyielding fascial and muscular partition 
which fills in the perineum, and the superior 
surface supporting only the under wall and 

fRead before the Medical Society of Virginia,* at 
Chase City, Nov. I5th-i6th. 



neck of the mobile bladder: this organ on 
increasing in size, whether symmetrically 
or asymmetrically, uniformly or eccentric- 
ally, spreads out in the line of least resist- 
ance which is upward and backward. 

It is by rectal examination with firm 
counter pressure over the pubes, that the 
organ's size, contour, location, consistency, 
symmetry, and character can he satisfac- 
torily determined, and the neighboring 
glands readily palpated For secondary in- 
volvement, and supplemented by urethral 
capacity, mensuration and cystoscopic ex- 
amination, the compensation of the bladder, 
its future compensating possibilities, varices 
of the vesical floor, stone, inflammation, 
injection, pouches, diverticular, saccula- 
tions, ureteral continence, muscular hyper- 
trophy with concentric shrinkage, or mus- 
cular atrophy with eccentric distention, and 
the consequent capacity of the bladder are 
rapidly taken in. 

It is the muscular potentiality of the blad- 
der wall that determines the patient to seek 
medical advice. So long as the bladder by 
hypsrtroDhy and intrinsic effort overcomes 
the urethral resistance incident to enlarged 
prostate, just so long the patient is either 
unaware of his trouble or thinks sufficiently 
lightly of it to ignore medical advice, — at 
that moment, however, by virtue of ex- 
cesses, exposure, cold, constipation, etc., 
there is inaugurated a primary ultra-acute, 
venous, prostatic engorgement, the bladder 
is unable to conquer this slightly added de- 
mand to its failing and weakening power, 
there is acute retention, with its train of 
symptom complexes which demands imme- 
diate and competent surgical aid. 

There are a few of us present who have 
not seen this condition. 

The patient should be put instantly to 
bed and a high, hot enema immediately 
carried out, with precision and care. This 
is, the writer believes, of the greatest mi 
portance and value. For by unloading the 
rectum and lower bowel, exciting locally a 
circulatory activity, combined with the con- 
sequent massage incidenl to a hydrostatic 
pressure, the acute condition is frequently 
sid ■ track.-d in a most gratifying way. 
is!onally the hypodermic use of mor- 
phine for relaxation and quiet is of value 
particularly with marked tenesmus, strain- 
ing and evidences of haemorrhage. Hot 
stupes over the bladder region are prefer- 
able to the Sitz tub; for with the latter, the 
down hill position, and /one of unequal 
temperature, causes a still greater passive 
congestion to the submerged parts. It, how 
ever, may be tried if the hot water bag and 
applications to the bladder region prove of 
no. avail. It is now that gentleness, care, 
patience and asepsis are the veritable watch- 

words; the bladder will not burst, and the 
ruthless, inopportune, hasty use of an un- 
sterile and rough (or even sterile and 
smooth) catheter, at this time, has produc- 
ed far greater evil than if left to nature's 
method of finally voiding the urine, drop 
by drop, by a pressure anaemia. 

The cause of the acute retention is a suc- 
culent, oedematous, passive congestion, the 
prostate is soft and spongy, the mucous and 
submucous structures are injected, and 
there is a flow of se r mghout the 

organ, more into the ir \>sa and suhmucosa 
than elsewhere. How is it possible for a 
catheter, even of the smallest size, to locate 
and pass through an urethral opening 
through which a drop of water cannot find 
its way! The writer believes that in but a 
few instances does it find this opening, very 
mucli more often it does not, the tortuous 
and blocked prostatic channel, with vertical 
slit-like sides, does not allow of easy and 
immediate soundings. A metal or firmly- 
woven silk instrument, tends to keep on in 
its own axis, the soft organ is penetrated, 
gives way, the catheter is thrust on through 
the substance of the prostate until finally 
urine emerges after a blood clot has been 
thrown out, which the operator is astonished 
to see, but the retention of urine is relieved! 
Shortly there is a chill, the urine and pros- 
tate, heretofore clean, have become infected, 
the cause of the infection — the catheter; the 
source, the lacerated prostate. Aseptic 
preparation of the suprapubic region, a 
small >4 inch skin incision and the rapid 
thrust inwards of the trocar, thus attacking 
the bladder from behind the prostate and 
not through it, is surely based on better 
surgical principles. Repeated aspirations 
in this stage may be carried out with less 
risk of infection than by the use of a 
catheter. The trocar may be left in situ, 
syphonage being adopted, or irrigation of 
the bladder with astringent or antiseptic 
solutions is readily and easily performed. 
Regardless of how the bladder is gained 
some solution should always be thrown in 
after evacuation of the urine. The sudden 
let up of the hydrostatic pressure on the en- 
gorged veins of the submucosa gives rise to 
rupture, an intractable lnemor J hage follow- 

On the other hand, in the old, hard, long- 
standing prostatic hypertrophy in which 
the venous injection has long since under- 
gone a replacement fibrosis, the prostatic 
urethra is hard and well defined, its walls, 
though curved, are slick and resistant, and 
a soft catheter now inserted runs no risk of 
being shoved through the prostatic sub- 
stance. Even at this stage, however, care 
must be observed, for false pockets, due to 
traction diverticula, may be mistaken for 



the normal channel and perforated. An- 
other point to bear in mind is the "prevesical 
ox prostatic pocket, ' ' which is found peculiarly 
in the urinary obstruction of middle lobe 
overgrowths, this pocket filled with urine is 
formed in the prostatic urethra by a dilata- 
tion of its walls, bounded on either side by 
the lateral lobes, anteriorly by the cut-off 
muscle, and posteriorly by the enlarged 
ball-valve middle-lobe which fits snugly 
over the ve ' '"• -uing in the well described 
ball-socket k>. ... ,This prevesical or pros- 
tatic pocket may. hold from several drops to 
as many drachms of urine, which from time 
to time have trickled around the ball-valve 
or by its recession has allowed of the urine's 
escape. The catheter inserted now, goes a 
shorter distance, six to eight inches, meets 
no resistance and evacuates urine, only the 
contents of the pocket, however, no more. 
On further insertion the middle lobe is im- 
mediately located and felt, occasionally it 
may be shoved to one side, the contents of 
the bladder then being withdrawn. 

The writer had under observation such a 
case, the internal opening being plugged by 
a symmetrical, well-defined, globular, mid- 
dle-lobe overgrowth which was easily re- 
moved by the supra-pubic route. 

In those cases of prostatic enlargement 
characterized by marked venous congestion 
through pressure of the gland on the peri- 
prostatic plexus, varicosities of the floor of 
the bladder may be pronounced, so pro- 
nounced that the vein bursts into the cavity 
of the bladder and continues to bleed until 
the pressurs in the bladder is equal to that 
in the vein. About a year ago the writer 
witnessed the results of such a case in a 
laborer, 55 years old, who, for several years, 
had been annoyed only, with a nocturnal 
frequency of urination. On lifting a heavy 
weight, he felt something give way in the 
bladder region which was attended by some 
pain. Later, because he was not able to 
make his water, he called in a physician. 
On catheterization only clotted blood and 
urine, highly stained, was withdrawn, in- 
fection caused continued bleeding, so that, 
several weeks later, when first seen by the 
writer, the patient was suffering from mark- 
ed uro-sepsis, most anaemic, and in a piti- 
fully weakened condition. A supra-pubic 
cystotomy was performed, and irrigation of 
the bladder by iodine solution carried out 
three times daily, two weeks later the radi- 
cal operation was performed and the two 
moderately large lateral lobes were removed. 
The patient gained rapidly in weight and 
strength and in a short while was again at 
his work. 

Bleeding from the floor of the bladder is 
a much more frequent complication and 
epiphenomena of prostatic hypertrophy than 

is commonly supposed, the writer believes 
in a large number of instances it is the first 
trouble that attracts the patient's attention 
to himself; but this haematuria is usually 
empirically associated with malignancy or 

Operative procedures for prostatic hyper-' 
trophy should be attempted only by one 
who enjoys a thorough and intimate famili- 
arity with the perineum, for such a knowl- 
edge does not allow of injury to the rectum, 
to the seminal vesicles, lacerations of the 
base of the bladder, or uncontrollable 

Right here a practical point may be men- 
tioned, the arterial supply to the perineum 
is the internal pubic, which, escaping from 
the pelvis through the greater sacro-sciatic 
foramen, returns by the way of the lesser 
foramen to course upwards and anteriorly 
to supply the bulb, corpora cavernosa, and 
terminate as the dorsal artery of the penis. 
It is by retraction of this severed artery 
under cover of the falciform process of the 
greater sacro-sciatic ligament that alarming 
haemorrhage is produced. If the operator 
will locate the inner aspect of the promi- 
nent tuberosity of the ischium, the curved, 
sharp, falciform ligament is immediately 
felt, and under its cover lies the internal 
pudic which can be readily ligated or crush- 
ed against its bony back-ground. 

Having tried the bi-ischial, semilunar, 
the median and horse-shoe perineal incis- 
ions, the writer believes that the inverted 
"Y" is the one of choice. It gives all the 
room possible, and is made parallel with 
the arterial supply — an important factor — 
the membranous urethra is rapidly located, 
a prostatic retractor inserted, and the im- 
portant step of the entire operation is now 
at hand, "to clear the under surface of the 
prostate and its posterior wall from muscular 
and fascial attachment to the rectum." 

The levator ani swings antero-posteriorly 
in the pelvis as an incomplete hammock 
between whose deficient leaves interiorly, 
the protruding prostate is grasped. This 
muscle is easily stripped and held aside, 
presenting posteriorly the base of the pros- 
tate applied against the rectum by the short 
firm fibers of the recto-urethralis muscle. 
With curved scissors (the concavity against 
the prostate) the muscle is severed, the 
finger is inserted and swept around to be 
sure of the gland's freedom. A large 
(preferably Young's) perineal retractor is 
placed against the anterior wall of the rec- 
tum, which is shoved well back out of the 
way, the prostatic retractor is pulled down, 
and the gland is now satisfactorily in view 
and can be removed according to the oper- 
ator's selection. 

Fifteen to thirty minutes more spent in 



the careful preparation ami dissection of the 
operative field, identifying structures, and 
thoroughly and carefully freeing the pros- 
tate from its muscular attachments to the 
rectum, is insignificant compared to the 
months or ye irs of discomfort and unhappi 

Lused by its hurried and blind re- 
moval through a fit-id which lias been in- 
completely and unsatisfactorily opened up, 
and in which the prostate is taken by tear- 
ing and touch, and not by enucleation 
under guidance of the eye. Kor with a 
careful dissection and gentle traction the 
prostate is readily brought down flush with 
the perineal floor, where it may be held, 
palpated and incised under easy view. 

hi selected cases of lateral enlargement 
a median bar carrying the ejaculatory ducts 
is better left, the lateral lobes being readily 
taken away by incision from the sides and 
around this bar. In this way the procrea- 
tive integrity is maintained and the compli- 
cation of relapsing orchitis is dour away 

With urinary obstruction from purely 
middle lobe overgrowths the supra-pubic 
method is the better, although the writer 
removed through the perineum by way of 
the urethra a ro mded middle lobe about 

■ of a hazelnut. A large catheter 
for bladder drainage and irrigation is put 
in the urethral opening, the perineal wound 
-own up tight, with a small cigarette drain 
al its pendent angle, and the patient told to 
be up on the sec, wd day, the tube is reniov 
eil on the fourth day, after which the course, 

{? <~*U< 

convalescence, and treatment is practically 
that of an external urethrotomy wound. 
The arterial supply to the perineum is very 
generous, drainage is good, wounds have 
no difficulty in healing here. 

The writer submits three photographs 
illustrating the prostate, removed by No. 1. 
Supra-pubic prostatectomy "en masse." 
This is the method of choice of most English 
operators. In this operation the prostatic 
urethra is taken away with the gland, the 
hole in the floor of the bladder is large, 
drainage is imperfect, and despite claims to 
the contrary, until some method of more 
satisfactory drainage is established, the 
writer cannot see the advisability of per- 
forming this operation over that of the peri- 
neal mute. 

The dimensions of the organ are given on 
the photograph. 

Xo. .i. Supra-pubic prostatectomy for 
middle lobe over-growths. Which accord- 
ing to charade:-, and shape of base may be 
snared, cut or enucleated. In this case a 
longitudinal median incision was made, the 
middle lobe enucleated from around the 
urethra, and Hi,- smaller lateral lobes taken 
away through the same opening. The re- 
sults in this case were highly satisfactory, 
due, no doubt, to leaving the prostatic 
urethra intact. 



NO. 4. 

No. 4. — Perineal prostatectomy, lateral 
lobes being removed leaving: middle bar 
carrying the ejaculatory ducts. 

This latter operation, the writer is con- 
vinced, is the ideal method for attacking 
and removing the prostate for all forms of 
over-growth, except the ball valve over- 
growth of the middle lobe, which should be 
removed by the supra-pubic method. 

Were the prostate alone the only cause of 
the patient's condition it could be speedily 
remedied, but those conditions, which have 
been going hand in hand with the enlarg- 
ing prostate, have also been undergoing a 
pathological metamorphosis. Surgery can- 
not rectify in as many minutes conditions 
which have taken years to obtain. The 
bladder wall, the ureters, the pelvis and 
kidney substance, the heart, the arteries, 
the general anaemia, depletion, and uro- 
sepsis, incident to darning back of waste 
products, destined for excretion, — and not 
for systemic absorption, are also to be reck- 
oned with and cautiously weighed. 

In the normal man perineal prostatectomy 
is nothing more than a deeper dissection of 
an external urethrotomy, and should be 
attended with no more risk, but a prostat- 
ectomy is never performed in a healthy sub- 
ject, it is essentially a disease of advanced 
life, senile changes, contracted kidney and 
atheromatous arteries, pathological states 
which call for the physician's advice aside 
of any operative procedure. 

The anaesthetic, the shock, (primary and 
delayed ) haemorrhage, congestion of the 
kidney, uraemia, pulmonary oedema, em- 
bolism, lowered index of repair, and other 

less frequent complications and sequelae, 
are sufficient to pronounce the operation 
"of severe character, attended with more 
than the ordinary risk, "but with brilliant 
results in selected cases." 

The writer arbitrarily divides the Pros- 
tatiker's Life History into three stages. 

No. 1. — Enlarged Prostate, characterized 
by a moderate frequency of urination. 

Examination. — Bladder healthy. Resi- 
duum, two ounces or less, and clear, organs 
normal, general health excellent. 

No. 2. — Enlarged Prostate, characterized 
by "catheter life" or overflow. 

Examination. — Bladder tired out and in- 
fected . Residuum, large amount and nasty, 
kidneys and heart compensating, general 
health fair, able to attend to work. 

No. 3. — Enlarged Prostate, (really No. 2, 
plus systemic infection), characterized by 
acute retention or incontinence. 

Examination. — Bladder and kidneys in- 
fected. ' Residuum, the capacity of the blad- 
der, kidneys and heart not compensating, 
confined to bed, uro-sepsis, uraemia, delirium. 
( )f these, No. 1, with compensating clean 
bladder, organs normal and general health 
excellent — there is no indication for surgical 
interference. The patient should be told of 
his condition, warned of possible complica- 
tions, and advised to consult his surgeon 
every few months, who explores for enlarge- 
ment of the gland, examines the urine's 
residuum and washes out the bladder. 

No. 2 is really a compensating No. 1, 
plus infection; and is the type which sooner 
or later should find its way to the surgeon's 
table — and the sooner the better. With 
compensating organs, scrupulous cleanli- 
ness and care, this prostatiker may live out 
his allotted number of years, succumbing 
later to some intercurrent disease; but with 
the daily increasing danger of failure of 
compensation, and consequent systemic in- 
vasion, with their inevitable results staring 
him in the face, an early and radical opera- 
tion can be conscientiously advised, and 
earnestly recommended. It is this class 
which constitutes by far the majority of 
operative cases, the mortality bearing a re- 
markable ratio to operation before and after 
compensatory influences. 

No. 3 is the non-compensating prostatiker 
plus uro-sepsis. Radical procedures here 
are clearly out of the question. Permanent 
drainage of the bladder is all that should 
be attempted, but even this is usually not 
well borne by the septic, uraemic patient. 
The writer had under observation such an 
instance, — a man 84 years old, on whem a 
supra-pubic cystotomy was performed; the 
"systemic drain" did everything possible. 
In a month he had left the hospital much 
improved, the wound was allowed to heal 

1 1 


md at last 

iunts he was doinj 




>f the prostate with uriu- 
elativelv common con- 

In (•■inclusion, 

a. Hypertropkj 
ary blockage is a 

b. These patients should be constantly 
under their physician's observation and 

, . They should be warned of the compli- 
cations, and familiarized with the import- 
ance oi aseptic precautions. 

</. With the initial establishment of "ca- 
theter life" or with a large residuum, oper- 
ation should be earnestly advised. 

e. The operation of choice is the perineal 

f. Tin- patient should be up on the second 
day Following. 

g. Sparteine sulphate in these old kid- 
neys should be most cautiously employed. 
"Wash out with water and not with drugs." 

//. In the first stage do nothing radically. 
[n the second stage do the perineal opera- 
tion radically, in the third stage do the 
supra -pubic cysti itomj radically. 

i. In all three stages remember that other 
organs are to be seen to besides the prostate 

Surgery and the General Practitioner.* 

By J. VV. Ellis, M. !>., Umpasas, Texas. 
( ,v)il/cniiii. 

My object in this paper is to discuss the 
relation of the general practician to surgery 
and to urge him to be a better diagnostician 

•Read before Sau< lo 1 >isti ict 

ation at Lampasas, Oct. 23, 1907. 

and to apply his anatomical and surgical 
knowledge when urgency and humanity 
require. By a brief review of the history 
of medicine, we shall see that the attitude 
of our profession has changed markedly in 
reference to surgery. In ancient and medi- 
aeval times it was considered beneath the 
dignity of a physician to do any work with 
his hands for his patient, this being dele- 
gated to the barber who set broken bones, 
extracted teeth, checked hemorrhage, etc. 
But after the dissection of human bodies 
became permissable, establishing anatomy 
as an exact science, surgery received a 
direct impetus; yet, however, it could not 
attain its present proportions without the 
advent of embryology, histology, bacteri- 
ologv, and other sciences which have been 
developed in the last quarter of the nine- 
teenth century. So now at the present time 
this branch of medical practice with its 
retinue of specialties is well and lastingly 
established upon a scientific basis. 

I desire first to consider minor surgical 
work, the greater part of which is done by 
the general practician, since people do not 
often go to a surgeon to have boils and 
felons lanced or carbuncles treated. The 
general practitioner is the man most often 
consulted and the man who usually does 
the work for which he often does 1101 de- 
mand nor receive adequate remuneration. 
A physician will open an abscess, write 
two or three prescriptions for treatment of 
same, give general directions, and apply a 
dressing all for the pitiable fee of one dollar. 
Gentlemen, this fee is disgracefully low and 
beneath the dignity of a learned profession, 
and such is true of much of our work. Yet 
it is hardly fair to raise the price of services 
unless the service itself is made more effic- 
ient. We should examine our patients more 
carefully, for instance, make a chemical 
and microscopical urinalysis, make a blood 
count, or make a microscopical examination 
of pus or sputum or serum as the nature of 
the case may indicate. Every physician of 
this generation should have his office so 
equipped with instruments, surgical dress- 
in- material, X-ray, and static machine so 
that he can easily carry out modern diag- 
nostic procedures and institute modern 
rational treatment. Physicians ate prone 
to be negligent in their minor surgical 
work, and this tendency to slight the minor 
details conduces to the formation of the 
habit of carelessness, which habit will be 
carried into their major operations, often 
proving disastrous to patient and operator. 
Besides there is not a better opportunity for 
impressing upon the laity the value of 
cleanliness and asepsis than is offered by 
our less important operations, nor there is 
nothing that detracts more from a man's 



prestige than a dirty, bunglesome, minor 
operation. The laity will naturally con- 
clude that the man who is not careful and 
painstaking in his less important work is 
not the man to be trusted when life or limb 
is in jeopardy. 

A minor operation should be faultless in 
technique and observant of aseptic and anti- 
septic precautions. The operator should 
take into consideration the cosmetic results 
of the operation as well as the future utility 
of the part. This is especially important in 
females who are easily offended by the pres- 
ence of unsightly cicatrices. 

In opening an ordinary boil we are often 
too negligent about cleanliness. For this 
seemingly unimportant procedure the hands 
and instruments of the operator should be 
rendered aseptic — the hands by washing in 
soap and alcohol and the instruments by 
being passed through pure carbolic acid 
and through absolute alcohol. The site of 
the boil should be washed with green soap, 
plain water, and 95 per cent, alcohol. Ab- 
sorbent cotton should be placed about, life 
abscess before making the incision in order 
to take up and dispose of the- pits 'flowing 
from the incision. I am a'-.\ are that t'.ie'v 
are many who doubt- the necessity of ob- 
serving the above technique, reasoning that 
there is already an in lectioi? a-'id that clean-' 
liness will avail nothing." It is'aue th'at 
pyogenic organisms have already gained 
access to the part, otherwise the formation 
of pus would have been impossible, yet 
bacteriology teaches us that there are other 
organisms, as the bacillus tetanus, which 
may enter the abscess cavity by means of 
dirty hands or instruments and thereby set 
up constitutional disturbances of far greater 
gravity than those originally present. 

As to the amount and character of major 
surgical work that a general practician 
should do, a great deal depends upon the 
skill and facilities of the operator. Upon 
this point the opinions of physicians and of 
surgeons are at variance with themselves 
and each other. Vet we all agree that there 
are certain major operations which, when 
required, admit of no delay and therefore 
demand an immediate execution. The laity 
and the profession at large have a right to 
expect of the general practician the knowl- 
edge and ability necessary to recognize the 
nature of, and to institute the proper opera- 
tive procedures in all urgent surgical con- 
ditions. Why should the general practi- 
tioner not be able to inaugurate correct 
treatment in at least the most frequent 
emergency cases? We all, in our college 
days, received the same instruction and at- 
tended practically the same clinics. I be- 
lieve that when an emergency case happens, 
the general practician should shoulder his 

responsibility and with whatever assistants 
and facilities are at his command, should 
operate at once, especially if the life of<the 
patient is in imminent danger for want of 
operative interference. I believe, too, that 
the education of the general practician as 
found among the rank and file at the pres- 
ent time is adequate to warrant him in as- 
suming the responsioilities of grave surgi- 
cal conditions. We should, however, make 
frequent study of those grave emergency 
cases, so that when they arise we shall not 
be found wanting; and will be able to do 
the right thing at the right time, the element 
timeliness being an important characteristic 
of tiie product of every successful medical 

Obstetrical surgical work is usually very 
urgent in its nature and the practician 
should keep this ever in mind, not neglect- 
ing to be prepared when the crucial moment 
comes. In such conditions as rupture of 
the uterus, eclampsia, etc., we do not have 
time to call a surgeon. We must have the 
'knowledge and courage ourselves to open 
the' ; abdomen or apply the forceps if we 
would do all that our patient is entitled to 
receive from- otir hands. We should also 
attend to the minor' details of obstetrical 
practice such as 'lacerated perinei, which 
cause' the- woman aii untold amount of dis- 
comfort and suffering, and lacerated cer- 
vices which, aside from the inconvenience, 
are so conducive to the development of 
carcinoma of the cervix. It has been well 
said that the gynecologist thrives upon the 
sins of omission and commission of the ob- 
stetrician and if the latter always did his 
whole duty there would be little use for the 
former. Such is true to a more limited ex- 
tent with the surgeon and the general prac- 

Vet nothing in this article is to be taken 
as depreciating the value of the services of 
the surgeon to humanity and the medical 
profession. It is he who fearlessly inarches 
up face to face with the enemy and grapples 
with him in a hand to hand combat. It is 
he who has furnished the pathologist with 
material for his laboratory and research 
work and the student with specimens for 
his study and edification. The surgeon 
often does more for a patient by a few wise 
strokes of the knife than our pharmacopoeia 
would do in months or even in a life time. 
The man in the general practice who has 
his mind engrossed with the little aches 
and pains of Mrs. A., or who has sat up all 
night with Mrs. B. in a lingering case of 
dystocia, or who has spent the night in 
packing chalk roads or bogging in muddy 
lanes is not the man best qualified to do a 
clean, smooth, surgical operation. So ap- 
pendicitis, carcinoma of the mammary 



-land, sarcoma of the lower jaw, and all 
like conditions should be sent to the surgeon 
who in his more mature judgment and more 

extensive experience will be able to do the 
Lest thing for the patient. Vet I do not be- 
lieve that the general practician should re- 
solve himself into a bureau of reference, 
sending all his surgical work to the surgeon, 
his female patients to the gynecologist, or 
all his ear and eye troubles to the aurist 
and oculist. Such a course not only takes 
work from him which he should have and 
which he can do both to the satisfaction of 
himself and his patient, but it causes him 
self confidence which is one of the 
mi -; important elements in any physicians 
make up. And not dealing with these dis- 
I special organs, he will easily loose 
whatever knowledge he has gained of them 
during his transit through college and 
through the clinics. Knowledge not added 
to ami put into practice is dead weight and 
soon forgotten. Therefore, gentlemen, let 
us courageously do the things which of 
right belong to us, but let us be consarva- : 
tive in sending to the surgeon-', 'a lid the 
specialist those special cases 'tn^t' demand 
their attention. Let us follow' the dictum, 
'•Render unto ' .';esar . the', things that be 

The Relation of the Physician to the 

By Y. Berry, M. I)., Wetumka, Oklahoma. 

The physician in his daily avocation, if 
he is a thoughtful man and interested in his 
calling, is constantly reminded of the lack 
of interesl displayed by the community, as 
a whole, in medical matters. The varied 
SOCiologic phases, as well as scientific de- 
tails of our profession are as a sealed book 
to the average layman; and while it may be 
a profitless task to try to point out where 
the fault lays for this state of affairs, I be- 
lieve it will Le ,,i some Lenefit to the public 
as well as the profession to try to get to- 
gether ami understand more of each other. 
a profession engaged in the relief of 
human suffering is worthy of the thought 
ful consideration of all right-minded people; 
and I wish to impress upon every layman 
her.- tonight that the character of 
your doctors depend entirely upon vour ap- 
preciation of what a doctor should be 

The relation of the physician to the pub- 
lic i- paralleled by no other profession, and 
is only approached by that of the ministry. 
There is 110 trust so sacred as that of the 
life and health of the individual, and the 
communi ty at large, except it Le that of the 

'Read al an open session 1 to the general public) 
oi tlie Hughes County Medical Association, at 
Holdenville, okla., Nov. 12th, 1007. 

soul: and 1 am somehow of the opinion that 
if the possessor of the soul objects to its sav- 
ing the preacher will not count for much, 
anyway. However, we can not dispense 
with the labor of our over-worked and 
poorly paid minister, for we often need him 
to add the finishing touches to the doctor's 
futile efforts. 

( >ur profession is the only one of which I 
know that compels its devotees to answer 
the call of distress at his own peril and dis- 
comfort when he knows there is not one 
cent's remuneration in store as a reward for 
his services. Section I, of Chapter I, of 
the "Principles of Medical Ethics of the 
American Medical Association" says: 
"Physicians should not only be ever ready 
to obey the calls of the sick and the injured, 
but should be mindful of the high character 
of their mission and of the responsibilities 
they must incur in the discharge of momen- 
tous duties. :,: * * * ;,: :,: :,; * * 

These observances are the more sacred 
because, generally, the only tribunal to 
adjudge penalties for unkindness, careless- 
ness Or neglect is their own conscience." 

Section I,' of Chapter III, says: "The 
b;vadest dictates' of humanity should be 
■obeyed by physicians whenever and where- 
ever their services are needed to meet the 
'emergencies of 'disease or accident." 

•A T o fiver: sentiment ever actuated any 
class of men in any calling, and while there 
are those among us, as well as in all social 
and religious bodies, who do not come up 
to the standard, yet as a class we adhere 
strictly to the sentiments here inculcated. 
We have our selfish, unscrupulous adher- 
ents, but that should only make the pure 
gold shine the brighter. 

The confidential relation of the physician 
to his patient is one of the most sacred and 
delicate situations that can exist between 
two human beings, and he who would be 
so base as to betray it is unworthy of the 
calling. The doctor sees both tho physical 
and moral defects of his patient. The 
"family skeleton" is dragged forth in all 
its gruesome details for his inspection; the 
domestic life of his patrons is seen to the 
minutest detail during his professional 
ministrations, and it is his duty t) keep 
these secrets as inviolate as the tomb. 
Many a tragedy is known only to the family 
and the doctor. Many a home could be 
wrecked by a simple whisper from the 
Family physician, for we all know that 
since the fall of old Adam it is human to 
err, and that regardless of station in life; 
both in the church and out of it, and it is 
the faithful family physician who by his 
very training can look on the foibles of hu- 
manity with that charity that was taught 
by the lowly Xazareeu. 



When we realize the close relation exist- 
ing between the physician and his patient 
it is but natural that we should expect him 
to endeavor to correct some of the false 
notions held by the laity regarding our pro- 
fession. It has been said by some one that 
while the science of medicine has advanced 
marvelously during the past one hundred 
years, the people themselves have not ad- 
vanced one inch in one thousand years in 
their understanding of medicine as prac- 
ticed today. I believe this to be absolutely 
true, in a large sense. In an observation 
during twenty years practice 1 have met 
hundreds; yes, thousands of intelligent peo- 
ple, I might say educated people, who 
actually believed in superstition and sorcery 
in the treatment of disease. It has not been 
a month since I was told by a woman that 
she had cured her husband of malarial 
chills by tieing a red flannel string around 
his neck — regardless of the fact that he had 
been taking quinine for several days. A 
green string would not have cured him. A 
poor fellow was suffering from •"night 
sweats" as a result of a tubercular infec- 
tion of the knee joint. His wife "cured 
him" by setting a vessel of cold water 
under the bed — regardless of the fact that 
incision and drainage were instituted as 
measures of relief. We have all met the 
fellow who carried a buck-eye or potatoe in 
his pocket to "ward off rheumatism." Such 
nonsense is no less silly than the ancient 
Greek superstitious regarding Maudragora. 
It is superstition that makes you believe 
the being statement of the so-called Chris- 
tian Scientist — God save us from such 
science — when he tells you "there is no 
pain." Is it possible that any but a super- 
stitious person could believe that a limb 
could be torn from the body without pain? 
It was superstition and fanaticism, and 
they go hand in hand, that caused John 
Calvin to have Servetus, the great theo- 
logian and physician, burned at the stake; 
it is superstition and fanaticism that causes 
a loving mother to sit by the bedside of her 
dying diphtheritic child while a Christian 
Science Sorceress utters a lot of nonsensical 
gibberish over the innocent victim, in face 
of the fact, demonstrated thousands of 
times, that antitoxin will cure nearly every 
case if administered in time. One of the 
greatest obstacles today to the progress of 
scientific medicine is that where a patient 
recovers by the aid of nature, in spite of 
quackery, it is heralded to the four winds 
as the brilliant achievement of some ism; 
while the patient who recovers under scien- 
tific treatment attracts little, or common- 
place, attention. 

The charlatan, or quack, may be a very 
shrewd judge of human nature, and if so 

he knows how to play on the credulity of 
his victim, and especially on those who are 
really ill; for it is a fact that those who are 
afflicted by disease are peculiarly suscepti- 
ble to the influence of those who hold out 
alluring promises of relief, even though 
they are unreasonable. The p > >r, suffer- 
ing patient is like the proverbial "drowning 
man catching at straws," and the shrewd 
quack's chief stock in trade is a promise to 
cure even though it is impossible. 

The subject of quacks naturally leads to 
the subject of doctors advertising. People 
often ask why doctors do not advertise in 
the newspapers. And newspaper men often 
express concern that the doctor places a 
ban on newspaper notoriety. It is natural 
that the publisher should be interested, lor 
it is a matter of business to him. I can not 
explain our attitude on this subject better 
than to give the following hypothetical 
illustration; Let us suppose that all phy- 
sicians, as well as quacks, are allowed by 
custom to advertise their supposed merits 
in the weekly and daily papers. Suppose 
that during the year Dr. Jones, a graduate 
of one of our best medical schools, a man 
of high professional skill and a high sense 
of honor and several years experience, 
moves into your community for the purpose 
of practicing his profession. Suppose that 
following Dr. Jonesclosely comes Dr. Brown, 
a shrewd, sharp, polished fellow "from 
back east," who has never seen the inside 
of a medical college, or may be has attend- 
ed one or two courses at a second rate 
school, but by smooth manipulations and 
"pull" has secured license to practice. He 
may be an unscrupulous scoundrel covered 
with broad cloth and a silk hat, and ride in 
an automobile, and yet be entirely ignorant 
of the principles of the profession he pre- 
tends to adorn, but he can rattle off tech- 
nical jargon sufficient to make the uniniti- 
ated stare in amazement, though his jumble 
of words may have no more real meaning 
than the idiotic nonsense in Mrs. Eddy's 
rubbish. He advertises, though, and in 
flaring headlines claim to cure even- known 
disease from chicken pox to consumption- 
On the other hand Dr. Jones modestly an. 
no luces that he is in your town, and can 
b ■ f mud at such a place at such an hour, 
and will respond promptly t > your calls. 
Suddenly the little daughter of Mr. and 
Mr;. Smith is taken very ill with a pain in 
the right side, fever, vomiting, and rigid 
abdominal muscles. In their distress Mr. 
and Mrs. Smith cast about for a physician. 
T.iey have read the ad. of Dr. Brown, and 
perhaps have not even noticed the modest 
card of Dr. Jones. Dr. Brown positively 
says he cures everything, and as that is the 
kind of physxian they want he is sent for 


in haste. There is another very attractive 
for employing Dr. Brown. He says 
he cures all diseases "without the knife." 
lie eveu discards the scissors and saw. and 
of course Mr. Smith don't want any knives, 
or saws used on his child. Dr. 
Brown arrives with great flourish. Me en- 
ter-- the room with a pompous air, and after 
a period of deep meditation his countenance 
assume- a v\ ise expression and he announces 
that the little sufferer has "congestion of 
the bowels," and that with very close atten- 
tion he thinks he can pull her through "if 
the medicine will act." It would be un- 
necessary for me to say to a physician that 
there is no such disease as "congestion of 
the bowels," or of anything else for that 
matter; but the term has been used to cover 
many a hellish crime; it has tolled many a 
funeral bell, and has covered the ignorance 
of main- a quack. Dr. Brown applies a 
poultice, gives some nauseous concoction 
and goes forth to other victims. Alas! "the 
medicine never acts" — in the way he had 
In from a few hours to a few days 
we find the little sufferer "resting easy." 
It is the ease before death from general 
peritonitis, as a result of a ruptured septic 
appendicitis, and in a few hours a mothers 
darling will be tenderly lifted into a little 
white box and lowered to mother earth as a 
sacrifice to ignorance, superstition, and 
credulity. If Dr. Jones had been called he 
would have made a diagnosis at a glance, 
for there is no disease easier of diagnosis, 
and instead of expecting to perform a mir- 
acle — the Good Book tells us miracles are 
no nioii — with drugs he would have called 
a competent surgeon, if not one himself, 
and the idol of a mother's heart would 
probably have been spared to grow up to 
useful womanhood. Now any one that has 
eyes to see and ears to hear readily knows 
that I have not overdrawn the picture, and 
that the universal custom of advertising the 
supposed merits of physicians would lead to 
just such tra I have related. My 

personal belief is that it would be a national 
calamity, dragging our profession in the 
mire and slime of public ridicule, and de- 
stroying that dignity that should be the 
I to all learned professions. This 
would not be so, perhaps, if all medical 
men were of equal attainments and integ- 
rity, but, alas! they are not and never will 
be. Advertising would let the bars down 
to the unscrupulous scoundrel and be no 
advantage to the honorable physician. 

This leads me to a tew thoughts on the 
doctor who is always itching for a write-up 
in the "locals" regarding some wonderful 
surgical operation, or other professsional 
achievement. You have all read something 
like this: "A ten pound boy arrived at the 

home of Mr. John Jackson yesterday. Dr. 
Corncob reports Mr. Jackson able to be 
about." Now do you suppose that Dr. 
Corncorb got his name mixed up in the 
newspaper by accident? The editor of the 
paper did not care a fig whether Dr. Corn- 
cob, or Dr. Blowhard, or any other doctor 
was the physician in this, or any other case; 
but Dr. Corncob is a subscriber, and, per- 
haps, carries a professional card and gets a 
little stationary printed occasionally, so he 
"grafts" on the newspaper man for a little 
free ad. I say this is the case nine times 
out of ten, though I would say that some- 
times a newspaper man through friendship 
for a physician will put such stuff in with a 
mistaken idea that he is doing him a per- 
sonal favor. However, it is not only a 
great wrong to the physician so "favored," 
if he be of any standing in his profession, 
but is a grave injustice to his competitors. 
Allow me to say, though, that as a class 
newspaper men are gentlemen, and when 
the situation is explained to them they will 
gladly acquesce, and willingly aid us in 
eliminating those who are trying to "graft" 
on them for free self-advertising. 

I do not wish to be understood as saying 
that social and business movements of phy- 
sicians are not to be recounted in public 
print. They are to be treated in this respect 
just as other mortals. It is only their pro- 
fessional relations with patients, and the 
laudation of professional achievements that 
are tabooed. 

I am sorry that the heroes of medicine are 
not known to the general public. I only 
wish you could know something of Lord 
Lister, of England, who exposed himself to 
malignant infection from dangerous wounds 
swarming with millions of poisonous germs 
that he might work out the principles of 
antiseptic surgery, those principles that 
have banished hospital gangrene from the 
face of the earth, and made operative sur- 
gery one of the greatest blessings ever be- 
stowed on mankind, and saved tens of thous- 
ands from an untimely grave, You are all 
familiar with the life of the great Napoleon 
Bonaparte, the man of blood who caused 
the death of over two million of his country- 
men, and caused France, his native land, 
to trail her garments in poverty and untold 
woe, yet who of you can tell me of Lister, 
who has brought joy and happiness to mil- 
lions of people and hundreds of thousands 
of homes by saving the lives of their loved 
ones? \\ ho would not take off his hat to 
such a hero? Talk about doing honor to a 
Xapolean, or an Alexander the Great! They 
dwarf in comparison. 

Think of the heroism of the great German 
scientist, Pettinkofer, when after swallow- 
ing a glass of water swarming with millions 



of cholera germs as a test of the mode of 
conveyance of this dread disease, who on 
being asked if it were not better that one of 
his younger and less useful assistants take 
such a dangerous risk, replied: "I have 
every right to consider that my bodv is 
worthless. 1 am seventy-four years old. 
* * * * * * " * * 

liven if the experiment took away my life, 
I should look death calmly in the face. 
For it would be no thoughtless and cow- 
ardly suicide. I should die in the service 
of science as a soldier on the field of battle. ' ' 
Think of the brave Surgeon Major Ross, 
of the English army, who searched the 
deadly swamps of India for two and a half 
years for the type of mosquito that trans- 
mits malarial infection to human beings. 

Let us learn of Kitasato and Aoyama, 
the Japanese physicians, and Yersin, the 
Frenchman, who risked their lives hundreds 
of times in the study of that most dreaded 
of all diseases, bubonic plague. Aoyama 
experimented once too often, and forfeited 
his life. 

In the clinical amphitheatre of the great 
Johns Hopkins Hospital, at Baltimore, you 
can see a plain tablet in the wall which 
reads: "In Memory of Jesse Williams 
Lazear.' ' This is the simple token in mem- 
ory of this young- American physician who 
voluntarily exposed himself to the bite of 
the type of mosquito which was supposed 
to transmit yellow fever to the human sub- 
ject. The supposition proved only too true, 
and Dr. Lazear gave up his noble life that 
you and I might be able to avoid this dread 
disease. Drs. Reed and Carroll, two other 
American physicians were associated with 
Dr. Lazear in these experiments, and Dr. 
Carroll has recently died of a weak heart 
induced by experimental inoculation of 
himself with yellow fever germs. It can 
also be said that Dr. Reed gave up his life 
in the same experiments. 

It should make one proud that he is an 
American citizen when we recall such sacri- 
fices as these in the cause of humanity. 

I could spend hours telling you of the re- 
lation of the physician to the public in 
hygienic and sanitary affairs, and how, if 
only given a chance, the doctor could be 
made an asset of incalculable value in 
every community, but time forbids. 

In conclusion I hope 1 may be pardoned 
for wishing this meeting may result in 
bringing about a closer and more helpful 
alliance between you and your doctors. 

I beg of you that you aid in every way 
the honest, conscientious physician who is 
striving to master his profession in a scien- 
tific and dignified manner. On the other 
hand, it is your duty to "make it warm" 
for the charlatan, or quack of every descrip- 

tion, so that he will tarry not, but will seek 
pastures new, and fields of a more verdent 

Pain and Blood Pressure. 

Curschmann '(Munclfener medizinische 
Wochenschrift, ) investigated the question 
of the behavior of the blood pressure in the 
presence of painful stimuli. For this pur- 
pose he subjected various groups of indi- 
viduals to painful electrical stimuli, record- 
ing the blood pressure before and after. 
One set comprised persons with normal 
sensibility; these reacted with an elevation 
of <S to 10 mm. of Hg. , though in two out 
of twenty a drop of 10 to 15 mm. was 
caused. In persons with neurotic or or- 
ganic hypertension the elevation produced 
was still greater, and the author considers 
that it may be accepted that both in well 
and sick persons with normal skin sensi- 
tiveness the application of painful stimuli 
causes a rise in blood pressure, more rarelv 
a fall. In disturbances of sensibility either 
through organic disease or hysteria, this 
result did not follow. In gastric and intes- 
tinal crises in tabes the blood pressure was 
found to be very high as well as in lead 
colic, whereas in instances of abdominal 
pain due to other causes, such as carcinoma 
of the stomach, gallstones, etc., this was 
not the case, and he suggests that this sign 
may have diagnotic value. 

Wine and Typhoid Fever. 

Carles discusses the question whether the 
use of wines to modify water that is sus- 
pected of impurity will be any safeguard 
against typhoid fever. He has made ex- 
periments with various forms of French 
wines as to their effect on the typhoid fever 
germs, and finds that some of them have 
an appreciable bactericidal quality which 
is not dependent on the amount of alcohol 
that they contain, since it is not diminished 
by heating the wine and thus driving off 
the alcohol. White wines are more active 
than red ones, and especially champagne is 
valuable. The degree of acidity of the 
wine appears to be an important quality, 
since the use of an alkali destroys its bac- 
tericidal power. The amount of fluid with 
which the wine is mixed, as well as the 
time it is allowed to stand, both affeet the 
bactericidal qualities of wite. Making the 
mixture some time beforehand and allow- 
ing it to stand before giving it to the pa- 
tient has been found to be favorable to this 
power. — Journal de Medecine de Bordeaux. 

Frequency of Tuberculosis In Infancy. 

Lomini believes that tuberculosis in in- 
fancy is much more frequent than has been 



nized. Autopsy shows this to be the as to be rather larger than a goose s e SS . 
These forms of tuberculosis may There were no adhesions. The liver was 
remain latenl for years and only he re- enlarged and was dark purple in color. L 
vealedbyautopsv. He collects and tabu- was firm in consistence. 1 he peritoneal 
late the cases on which autopsies were cavity having been shut off with large 
made at the Pediatric Hospital in Florence, gauze pads, the gall-bladder was opened 
from 1902 to the present time. From 437 and a large quantity of clear glairy fluid 
autopsies on babies, 186 showed tubercu- escaped. Three small black mulberry - 
losis The respiratory organs were found shaped calculi were fished out of the gall- 
to be very frequently involved, while the bladder, which was now m a collapsed con- 
intestines and abdominal organs were much ditiou. Xo stones were discoverable by 

equently affected —La Pediatria. palpation in the cystic duct. < hi the under 

surface of the right lobe of the liver was 

Diphtheria. Irregularity of the Pulse In. f oun( -l an irregular whitish scar about the 

Peters (Lancet) considers that irregular- size of a sixpence. On drawing the liver 
itv of the pulse in diphtheria in children is upwards a hugely dilated common bile duct 
really of little special significance, being was brought to view, and on tracing this 
due to the -real incidence of the disease in down it was found to lead to a hard mass 
the earlv vears of life, especially the fourth in the position of the head of the pancreas. 
and fifth year. Children at this age com- Several smaller nodules, thought to be en- 
monly exhibit this symptom in any febrile larged glands, could be felt extending to- 
disturbances and often in apparent health, wards the foramen of Winslow. The di- 
The irregularity is very common, indeed, lated duct was almost as large as a piece of 
it being found in over 80 per cent, of the small intestine. An attempt was made to 
author— cases. Comparisons of similar empty it by massaging its contents through 
numbers of diphtheria and scarlet fever the cystic duct towards the gall bladder, 
cases showed about the same percentage of but without success, owing to some diffi- 
cardiac irregularity. The irregularity is culty at the neck of the gall-bladder, the 
referred by various authorities to a nervous nature of which could not be determined. 
origin, rather than a cardiac. There seems Accordingly, it was decided to drain the 
to be an excessive susceptibility in the in- common duct by anastomosing it with the 
hibitory action of the vagus, and it is be- first part of the duodenum. This was ae- 
lieved that the rhythmical stimulation of complished with some difficulty, on account 
the respiratory center has a rhythmical of its deep position, by means of a small 
effect on the vagus center. The author re- Murphy button, using fine silk for the 
fers to Barr's explanation of the mechanical purse-string sutures and several reinforcing 
effect of the respiratory act on the circula- Lembert stitches to prevent possible leak- 
tion. The fall in blood-pressure in disease age. Before placing the female portion of 
is undoubtedly the primal cause setting up the button in the duct an incision was 
the irregularity. made into the latter and a large quantity 

[f actual myocarditis is present, an irre- of glairy fluid with no trace of bile in it 
gular pulse is, of course, of the gravest was quickly mopped up. The finger could 
significance. In most diphtheria cases be introduced into the duct and passed up 
with irregularity the latter continues dur- into cavities in the liver corresponding with 
ing hospital stay, and the children are the dilated hepatic ducts. To facilitate 
kepi in bed week after week when they manipulation of the parts it was found 
would do better if in the open air, which necessary to make a transverse incision at 
would certainly improve their anaemia, right angles to the upper end of the origi- 
Assurance must firsl be obtained thai the nal wound in an inward direction. The 
irregularity is more than respiratory. The button having been satisfactorily adjusted, 
ence or absence of cardiac signs will the abdominal cavity was mopped dry and 
help decide this point. a stab puncture was made in the loin to 

Anaamnnsis iifliwoen the Common niie provide drainage. A split rubber tube with 

Duct and the Duodenum for Obstruc- a gauze core was passed through the open- 
tlvo Jaundice. m g so made. The wound in the gall- 

Fullerton (Brit. Med. Journal,) reports bladder was sutured to the peritoneum and 
the following operation done on a man of transversalis fascia and the viscus was 
sixty-six years. The patienl had lour drained by a rubber tube which led from 
doses of calcium chloride, fifteen -rains its interior to a sterilized bottle. The ab- 
everv four hours, the day previous. A dominal wound was closed with through- 
vertical incision five inches long was made and-through sutures of silkworm gut, and 
over the most prominent part of the tumor lne patient was returned to bed, having 
and the abdominal cavity opened. The stood the operation well. Five months 
gall-bladder was found to be distended so later the patient was in good condition. 



Charlotte Medical Journal 

No. 36 South Tkvon Street. - - - - 
Charlotte, N. C. 


We learn that the directors have recently 
purchased a tract of land at Montrose, 
Cumberland county, containing 948 acres 
upon which will be established the Sana- 
tariuni for which the last legislature appro- 
priated a large sum of money. The price 
paid was $7,700. It is said that work will 
begin upon the buildings at an early date. 


The State Board of Health has recently 
appointed Dr. C. A. Shore, a native of 
Salem, to take charge temporarily of the 
State Laboratory of Hygiene during the 
disability of the director, Dr. Gerald Mc- 
Carthy. Upon the expiration of his term, 
March 1st, 1908, Dr. McCarthy will retire 
from the position after a long term of most 
satisfactory service. Dr. Shore was elected 
at a recent meeting of the Hoard of Health 
to succeed the present incumbent, and on 
March 1st he will assume entire control of 
this important department. 

Dr. Shore is a graduate of the State Uni- 
versity and has a degree of M. D. from 
Johns Hopkins. The State is fortunate in 
its choice of this gentleman. He is emi- 
nently fitted for the position. The office 
and laboratory are on the third floor of the 
Agricultural Building and there is a very 
complete equipment. It is a very important 
sub-department and the State Board of 
Health and the Agricultural Department 
co-operate in regard to it. 


The Greensboro Cottage Sanitarium, for 
the treatment of tuberculosis, opened Janu- 
ary 1st, 1908. Dr. Jno. R. Williams is 
Medical Director, Dr. Win. M. Long, assist- 
ant Medical Director, and Dr. W. P. Reaves, 
visiting Laryngologist. The Journal be- 
lieves in the cottage plan of treatment and 
is pleased to see so much being done in 
North Carolina toward the eradication of 
the great White Plague. We wish for Dr. 
Williams and his associates great success 
in their undertaking. 


The Journal notes the opening, at Lum- 
berton, of the Thompson Hospital, Dr. X. 
A. Thompson, Resident Physician and 
General Manager. This institution is pre- 
pared for the treatment of all non-contagious 
medical and surgical cases. It is thoroughly 
equipped with modern appliances, hot and 
cold baths and has a competent corps of 
trained nurses. A specially noteworthy 
feature is a department for the scientific, 
ethical and humane treatment of whiskey 
and drug habits. We bespeak for Dr. 
Thompson success in his enterprise. 

The Southern Association of Medical 
Colleges held its twentieth annual meeting 
at New Orleans December 16, 1 ( )07. Fifteen 
schools were represented. Among the many 
important questions discussed by the associ- 
ation, perhaps the one of most far reaching 
interest was that pertaining to the advis- 
ability of demanding a four-year high school 
course as a qualification for entrance into 
Southern Medical Colleges. The resolution 
was referred to a committee appointed to 
investigate the matter. This is but another 
evidence of the general tendency making 
all over the country toward raising the 
standards of medical education. It is com- 
ing and we pray that it may be soon. 

The Crowell Sanatorium, Charlotte, X. 
C, for the Treatment of Alcoholic, Drug 
and Nervous Diseases, Dr. S. M. Crowell, 
was re-opened January 1st, 1908. 

Dr. Crowell has already established his 
reputation as a specialist on the diseases 
for the treatment of which his institution is 
established. His well known ability makes 
re-introduction unnecessary . 

The regular meeting of the Forsyth 
County Medical Society was held Dec. 10, 
1 9< i~, in the Winston-Salem municipal build- 
ing and was largely attended. There was 
much interest in the annual election of 
officers, which resulted as follows: Presi- 
dent, Dr. D. N. Dalton; vice-president, Dr. 
R. D. Jewett; secretary and treasurer, Dr. 
Kugene Gray. Dr. J. Lewis Planes was 
elected a delegate to the State Medical 
Society, which meets in this city next year. 
Drs. E. A. Lockett and H. S. Lott were 
elected members of the executive board of 
the Twin City Hospital Association and 
Drs. C. L. Summers and H. F. Pfohl were 
elected members of the training school 

Dr. R. D. Jewett read a most interesting 
paper on general diseases of the eye for the 
benefit of the general practician. 


The Guilford County Medical Society, at 
its regular meeting, held in Greensboro 
December 6, elected the following officers 
for the ensuing year: President, Dr. John 


R. Williams; vice-president, Dr. William P. 

Beall; secretary-treasurer and delegate t<> Much space has been devoted during the 

the State Societv, Dr. Edmund Harrison, past lew years to the threatening of our 

and censor, Dr. William 1. Richardson, all shores by the dreaded scourge of the east; 

of Greensboro. yet the medical press has not realized 

At the recent meeting of the Cabarrus the importance of the situation. Informer 

County Medical Society the annual election issues we have remarked upon the wide- 

of officers resulted as follows: President, spread invasion of the world by Bubonic 

Dr. 1). Greenlee Caldwell. Concord; vice- Plague, and while the eastern and southern 

president, Dr. fames C. Black, Harrisburg; States seem far removed from even the 

secretary-treasurer, Dr. J. Edward Smoot, possibility of its appearance, the truth 

Concrd. and delegate to the State Societv, nevertheless is thrust upon us that it has 

Dr. William D. Pemberton, Concord. existed for several years upon the Pacific 

coast, and but recently a new outbreak of 

TR I -state medical, assogiation. considerable proportions — considerable 

The regular annual meeting of the Tri- enough indeed to cause some anxiety to 

State Medical Association of the Carolinas thinking men — has occurred. It forces 

and Virginia will be held February 18-19, upon us the conviction that with all our 

1908, in Charlotte, X. C. Dr. Stuart Mc- boasted civilization there is yet much to be 

Guire, of Richmond, is President, and Dr. done in the way of sanitary control. The 

1. Howell Way, of Waynesville, X. C, is blindness manifested in the opposition of 

Secretary-Treasurer. The Journal hopes municipal authorities and of the lay press 

for a full attendance in the Queen City, in San Francisco upon the appearance of 

There are memories lingering yet in many the disease in that city in 1900 and 1901 is 

minds of the manner in which we of Char- yet fresh in the minds of many. The nar- 

lotte entertain. Come again and our hos- rowuess shown in the fight made against 

pitalitv shall not be less. The program of publicity as to the exact condition of affairs 

the meeting will doubtless be an interesting is nothing short of mediaeval. Those who 

one, since the Association is composed of asserted the existence of plague were reviled 

those who stand highest in the profession of and abused, and strenuous opposition and 

the component States. denial met every attempt to institute inves- 
tigation or establish quarantine. Many are 

the medical briet cmainges hands, reminded of the fight made by Kinyoun, 

The Journal notes, not without a certain then in the United States Public Health and 

sorrow, the retirement of Dr. J. J. Lawrence, Marine- Hospital Service, and the heart 

for thirty-five years editor, publisher and breaking manner with which his positive 

proprietor of the Medical Brief. At his assertions as to the presence of plague were 

seventy-second year, Dr. Lawrence has swept aside. Subsequent developmei.t shave 

decided to give over Ins work into younger amply vindicated him. 

hands and to retire from business of everv The startling rapidity with which bubonic 
kind. As he says: "the time has come plague has spread from its home in the East 
when he feels thai he would like to rest— to is amazing and we sit idly by while millions 
gel away from all turmoil and strife, and are sacrificed annually to its insatiable 
for the remainder of his days pursue the greed. In March, 1900, the first death 
even tenor of his way 'along the cool seques- from bubonic plague, verified by bacterio- 
tered role of lite.' " Dr. Lawrence has been logical examination, occurred in San Fran- 
a strong figure in medical journalism. ci sco. Other cases soon followed and the 
Always an independent thinker he has warfare on the medical profession and be- 
never failed to fight for that which is right, tween its members was precipitated. In 
a brilliant mind his writings January, 1901, the notorious Schmitx be- 
have not faded in leave their impress. The came mayor of San Francisco and he with 
Medical Briej passed into the hands of Mr. the Governor of California and the news- 
Henry R. Stroii-, a successful publisher, papers of the city, as well as the State 
who promises to continue the publication Board of Health and in fact a majority of 
of th'- Brief. We trust that the new will be San Francisco's doctors of medicine, array- 
as - 1 as the old . Here's to him the very e ^ themselves against the City Board of 

besl good-wishings! Health, tin- United States Public Health 

and Marine Hospital Service, and a minor- 
iiv of the physicians. As a result quaran, 

Dr. F. M. Winchester, Charlotte, \. C, tine and sanitary measures were defeated- 

has been elected recently to the Board of publicity through the newspapers was de- 

Ilealthofthecitv. He is a man well quali- llie d and the clamor of the ring above 

fied to serve on so important a body. We nam ed against common-sense proctetive 

congratulate the it 5 on its choice. measures was continued in the face of the 


positive official report of the commission shown himself the man he should be. The 
appointed by Surgeon-General Wyman and county Medical Society has accomplished 
consisting of Drs. Simon Flexner, F. S. much good by its investigations and as a 
Novy, and Lewellys F. Barker. As a re- result of an appeal to President Roosevelt 
suit plague spread to towns in the vicinity the United States Public Health and Marine- 
of San Francisco, and while confined chiefly Hospital Service has been placed in charge 
to Chinatown still there have been many of the plague work, with Dr. Rupert Blue, 
genuine cases among the whites. There passed assistant surgeon in charge of the 
are no means by which it is possible to say work. 

how many cases have existed, yet we dare Active measures have been adopted, 
say only a fractional part have been re- financial aid being given by the National 
ported. liven after Dr. Rupert Blue, of Government, yet the work is still inadequate, 
the Public Health and Marine-Hospital The newspapers, while not continuing their 
Service was placed in charge, in 1903, this positive abuse and open opposition, still 
opposition continued. But with active and tacitly refuse to lend their aid as they should 
systematic work, destruction of plague foci do. Quarantine is imperfect and the force 
and rat extermination the plague subsided, employed inadequate. 

It is interesting to note in passing that The Jour. A. M. A. to which we are in- 
the ground-squirrels in the districts around debted for this outline of facts thus sum- 
the city have acted as carriers of the infec- marizes the situation: 

tion to a greater extent than have rats. Active and thorough anti-plague work is 
Both of these small animals are infested being done in San Francisco and Oakland, 
with fleas and both have been found to die including inspection of all dead, isolation 
in numbers of bubonic plague. However, of all suspects, destruction of suspected in- 
iu the city itself rats seem to be the chief fected material, clothing, etc., and the de- 
carriers, struction of large numbers of rats by poison, 

From 1903 to 1906, there followed three Danysz's virus, trapping, etc. The sewer- 
years apparently free from plague. Whether men report that they never saw so many 
this is largely due to the continued domina- dead rats in the sewers, so it may be assum- 
tion of the opposition ring and their sup- ed that a Danysz of high viruleucy has 
pression of knowledge of the existence of been prepared and put out. Nevertheless, 
the disease is uncertain. Doubtless it re- while the number of cases seems to be some- 
mained in certain localities, for since the what on the decrease, in San Francisco, 
earthquake and fire of April, 1906, the the territory over which the infection has 
epidemic has broken out afresh and with spread is constantly increasing. Outside 
renewed vigor. of San Francisco, something is being done; 

Immediately the theory presents itself but in comparison with the danger of exist- 
that conditions following this catastrophe ing undiscovered foci, and of cases occur- 
were admirably suited to the outbreak of ring which may and probably do go un- 
any latent infection which might have been recognized, and of the great amount of 
harbored in the ruined city. Undoubtedly work which the State should be doing, it is 
remaining foci of the burned district were not encouraging, 
destroyed and thousands of rodents must 

have perished, yet thousands must have Society Meetings. 

been driven into the undamaged area of At the twelfth regular lannual meeting 
the city. With the general demoralization, an d banquet of the Buncombe County Med- 
the destruction of sewerage system and ical Sodety) held at Asheville, December, 
water supply, the unhygienic and filthy .. . ,, ~, . . , 

conditions which unquestionably arose in 16 ' the following officers were elected, 
the camps and hovels of the homeless, President. Dr. Daniel Sevier; vice-president, 
together with the depression which resulted, Dr. Martin L. Stevens; secretary, Dr. Gail- 
everything favored the re-infection of the lard S. Teunent; treasurer, Dr. Thomas E. 
inhabitants. Foci appeared and existed in W. Brown; delegates to the state society, 
widely distributed areas and there is small Drs. Thomas K. W. Brown and Chas. W. 
wonder the infection has not reached even Jordan, and alternates, Drs. William P. 
greater proportions. Whittingtou and Owen P. Smith, all of 

Even in the face of these facts, the first Asheville. 
reported case occurred in May, 1907, since At the regular monthly meeting of the 
which date there have been found numerous Forsyth County Medical Society, held at 
cases. Figures may or may not indicate Winston-Salem, December 11, the following 
the real state of affairs. officers were elected: President, Dr. David 

With the downfall of Schmitz and his N. Dalton; vice-president, Dr. Robert D. 
tools a new order of things was instituted. Jewett, secretary-treasurer, Dr. Eugene Gray, 
The present mayor, Dr. E. R. Taylor, has and delegate to the state society, Dr. J. 



Lewis Haines, all of Winston-Salem. 
At the regular monthly meeting of the 

Durham County Medical Society, held in 
Durham, the following officeres were elect- 
ed: President, Dr. Archibald Cheatham; 
Dr. Archibald C. Jordan, and secretary. 
Dr. C. A. Woodard, all of Durham. 

At a recent meeting of the Jackson Coun- 
ty Medical Society the animal election of 
officers resulted as follows: President, Chas. 
J. Candler, Dillsboro; Secretary, A. S. 
Nichols. Svler. 

By request zee /user/ the following Commu- 

December 57, 1907. 

Editor Charlotte Medical Journal: 

Will you kindly insert the following in 
your paper giving it as prominent a place 
as i> ssible. 

'I'he writer desires information regarding 
any alleged recoveries or cures of inopera- 
ble or recurrent carcinoma of the mam- 
mary gland. 

If any case or cases are known to any one 
who reads th's circular and can be authen- 
ticated by facts as to the history and condi- 
tion prior to recovery and the length of time 
which has elapsed since recovery such in- 
formation will he appreciated and duly ac- 

Any well authenticated reports or recov- 
eries of carcinoma located in other parts 
than the mammillary glands will be wel- 

Cancer paste cures, X -ray cures, radium 
i ures, or cures as a result of of surgical op- 
eration are not wanted. 

Hearsay cases are not wanted unless ac- 
companied by name an address of the per- 
son who can give information first hand. 

1 1* trace Packard, 
17n Commonwealth Ave., 
Boston, Mass. 


On the evening of January 15, 1908, at 
Trinity Church, Charlotte, X, C, Dr. Bro- 

ump Xallc and Miss Sadie Belle 
I are to be married. Both are widely 

known and exceedingly popular. Dr. Nal- 
rous young physician of Char- 
lotte. Mis-, Mayer is the daughter of Mr. 
and Mrs. Minor Clinton Mavei , also of 

DR. J. I ■". BEAbL. 

Dr. lames franklin Beall, a prominent 
physician of Lin wood, died at 2:30 p. m., 
Dec. 7, 1907, after an illness of ten days of 
pneumonia. He was 73 years of age. 

Dr. Beall was a major and a physician in 

the Confederate army. He was a member 
of a prominent family of South Carolina 
and leaves many relatives all over both 
vState. Dr. Beall was a graduate of 
the University of Xew York. lie was a 
member of the Davidson county Medical 
Society and of the State Medical Society. 


Dr. vS. M. Deal died at his mother's home 
in Blacksburg, S. C, Dec. 10, 1907. He 
was buried under the auspices of the Knights 
of Pythias, of which order he was an en- 
thusiastic member. Dr. Deal was only 33 
years of age. After graduating' in medicine 
at the University of Maryland, he went to 
Columbia to practice his profession. He 
soon acquired a lucrative practice, but 
attacked by tuberculosis, he left Columbia 
and went to California, with the hope that 
the climate would restore him to health. 
His hopes were vain, however, and he soon 
returned home. He leaves a devoted wife 
and three little children, a mother, one 
brother, and one sister to mourn his loss. 


We note with sorrow the death of Dr. 
Geo. F. Shrady, of New York, on Nov. 26, 
1907. Pyaemia following an attack of gall- 
stones quickly proved fatal. Dr. Shrady 
has been a prominent figure in the Medical 
Journalistic world for many years. Born 
in 1837, he was graduated in medicine from 
the College of Physicians and Surgeons, 
Xew York City, in 1858. After the close 
of the Civil War in which he saw active 
service as a surgeon. Dr. Shrady returned 
to his native city to engage in practice. 
Early in his career he became identified 
with the Medical Times as reporter, and later 
became its editor. Upon the founding of 
the Medical Record, in 1866, he was its first 
editor and for thirty-eight years give his 
best thought and effort as a writer and his 
skill as executive manager to the conduct 
of the Journal. In 1904 he resigned the 
editorship of the Medical Record. This 
Journal adequately attests his ability and 
the high character of his work as editor. 

Aside from the numerous and valuable 
papers contributed to various medical 
journals he frequently published articles of 
a more popular character in the magazines 
and papers of the lay press. 

Dr. Shrady is scarcely less widely known 
as a surgeon and practitioner. Early mani- 
festing his special predilection for anatomy, 
he gave promise of great surgical skill, and 
his proficiency and the reputation which 
came to him amply justified the promise, 
yet because of his conservatism he never 
achieved the reputation he might have done. 
As a consultant and diagnostician, Dr. 
Shrady's services were sought and it is in 



tliese special lines that he was probably 
best known. 

From 1861 to 1S7 ( ) Dr. Shrady was secre- 
tary of the Xevv York Pathological Society 
and president of that organization in 1883- 
84. He had been president of the Prac- 
titioners' Society of New York and of the 
American Medical Editors' Association. He 
was a member of the Medical Societies of 
the county and of the State of Xew York, 
of the Xew York Academy of Medicine, of 
the Practitioners' Society of Xew York, of 
the New York Pathological Society, of the 
Harvey Society, of the American Medical 
Editors' Association, and of the American 
Academy of Medicine. He is survived by 
his widow, three sons, and a daughter. 

Dr. H. P. Loomls. 

Among the prominent men whom death 
has recently claimed, it is with especial 
sadness that we chronicle the passing of Dr. 
Henry Patterson Loomis, of Xew York 
City, Dec. 22, 1907. Dr. Loomis had 
scarcely reached his forty-ninth year and 
was at the very height of his intellectual 
p >wers and professional success when an 
attack of pneumonia quickly caused his 
death. The sou of the eminent Alfred 
I.oomis, he had followed in his father's 
footsteps, as teacher, general practitioner 
and hospital physician. We mourn his 
loss and sorrow with his bereaved family. 

Dr. Nicholas Senn. 

With the death of Dr. Nicholas Senn, 
the distinguished and famous Chicago sur- 
geon, Jan. 3, 1908, terminates the earthly 
career of one of America's most widely 
known surgeons. A native of Switzerland, 
Dr. Senn graduated in 1868' from the X T orth 
Western University Medical School, Chica- 
go. His numerous writings proclaim him 
a man of very great literary talents; and of 
his great scientific attainments we have 
likewise have evidence in his well known 
volumes on surgical subjects. 

During the Hispano-American war Dr. 
Senn was chief surgeon of the 6th army 
corps. More recently he had traveled most 
of the time, his letters published from time 
to time being highly interesting. Ill health 
had during the past two years debarred him 
from much active practice. 

It is thought that during his recent tour 
of S u h America the high altitudes of the 
mountians proved unfavorable to his mal- 

Dr. Senn was Professor of Surgery in the 
University of Chicago and also head of the 
Department of Surgery of Rush Medical 

Review of Southern Medical Literature 

A r nc Orleans Medical and Surgical Journal, 
November, 1907 . 
Bacteria Carried on Appendages of 
Musca Domestica (Domestic Fly). -Dr. 

E. P. A. Picklen after explaining numer- 
ous experiments says when we realize the 
danger from the carrying of bacteria which 
threatens us during times of widespread 
sickness one fundamental conclusion be- 
comes clear. Stringent measures must be 
taken to eradicate flies. We of the South 
are especially concerned, for our warm 
winters force on insects only a brief hiber- 
nation. Their capability for doing harm 
which corresponds to their activity, extends 
over the greater part of the year in many 
of the Southern States. We must realize 
too, that extinction to be efficient in the 
shortest time possible, must be directed not 
against the mature fly, but against its breed- 
ing, as the slipshod ordinances of X T ew 
( )rleans are directed against the breeding 
of mosquitoes. The task, however, will be 
far easier in the case of the M domestica 
than in that of the stegomyia because of 
the definite and prescribed breeding places 
of the former. All horse stables must be 
strictly supervised, and the manure ren- 
dered uninhabitable to the eggs and larvae 
of the fly. Spraying with a strong solution 
of bichloride of mercury is recommended 
by most authors. 

No matter how effective the method adopt- 
ed is in theory a competent core of inspect- 
ors should be appointed to see that practical 
results are obtained. The average dairy- 
man or stable owner thinks only of carry- 
ing out the letter and not the spirit of the 
law. Sanitation has no meaning to the 
class of people who should practice it most. 
Their utter ignorance of the danger from 
the prevalence of bacterial life unfits them 
for work which should be carried on with 
the utmost care and exactitude. These 
men carry the welfare of the community in 
their hands to a greater extent than they, 
or the great majority of people, can ever 
realize. In brief the effect of investigation 
upon the mind of any one who undertakes 
it will be to arouse the firm conviction that 
the time will come when it will have been 
proved that M domestica, the common 
house flv can carry, and in all probability 
has carried, every pathogenic bacterium 
known to science. 

Nashville Journal of Medicine and Surgery, 
November, 1907 . 

Mastoiditis: Its Management and Treat- 
ment.— Dr. 1. E. Wells believes if the phy- 
sician is fortunate enough to see a case of 


acute inflammation of the mastoid ct- lis in 
its Erst stage, before pus has formed, he 
should have the patient put to bed and kept 
quiet. Give a light diet consisting princi- 
pally of milk. Calomel should be adminis- 
tered in one-tenth grain doses every hour 
until a laxative effect lias been produced. 
Tincture of aconite in one drop doses is an 
excellent remedy in the early stages. 
Leeches should be applied to two or three 
places over the mastoid. The ice bag or 
cold coil should be applied over this region . 
But cold, under no circumstances, should 
he applied over this region. The author 
believe:: that a blister only aggravates the 
If under the use of antiphlogistic 
measures and the application of cold the 
pain and tenderness rapidly subsides and 
the temperature shows no evidence of septic 
absorption the chances are that no operation 
will be necessary. Hut on the other hand 
if pain continues, temperature high, and 
severe pain on pressure over the mastoid, 
the indications are for an immediate opera- 
tion. In mastoiditis internal, should chisel 
an opening into the cells, establishing com- 
munication with the antrum and attic, 
examining all portions of the mastoid, 
removing all softened bone and granula- 
tions, etc. In acute inflammation of the 
mastoid occurring in connection with acute 
suppurative otitis media after using the 
antiphlogistic measures, if the pain is not 
relieved and the drum head is bulging a 
free incision should be made, [f inflam- 
matory symptoms do not subside the ear 
should be douched with a saturated solu- 
tion of boric acid every two hours, or ac- 
cording to the amount of pain and discharge 
present. In case of scarlet fever or diph- 
theria the ear should be syringed out at 
least mice a day with bichloride of mercury 
solution L-3000. After the mastoid cavity 
has been opened up and cleaned out should 
irrigate the cavity with bichloride of mer- 
cury solution 1-3000 and should try and 
ome of t! u - solution through the 
antrum and the external meatus. The 
cavity of the bone should be packed with 
strip- of moistened iodoform gau ze. 

The . Imerican Practitioner and News, Nov., 
Hay Fever. Dr. J. M. Irwin believes 
thai ii at the beginning of the hay fever 
season the patient is in robust health no 
preparatot mi di< ation i an do any good, 
but if the system is ou1 ol health general 
principles should govern the treatm< 
the disordei progresses the appetite fails; 
the patient becomes nervous and irritable; 
the hearts action quickened and weakened, 
and the various organs of the body Income 

sluggish in their action. Such remedies as 
are indicated may be given. For one week 
before the onset of hay fever, and through- 
out the whole course of the disorder, one 
drachm of sweet spirits of nitre may be 
given in a tumblerful of water three times 
daily, which will exert a decidedly bene- 
ficial influence in lessening the severity of 
the attack. When cedema of the bronchi 
occurs heroin one-sixth grain and atropia 
sulphate one one-hundred and fiftieth grain 
given hypodermically will afford relief. 
Asthmatic attacks are best relieved by the 
hypodermic use of heroin one-sixth grain 
and hyoscine hydrobrom one two-hundredth 
grain. When the abdomen becomes sud- 
denly distended with gas, causing much 
distress, morph. sulph. one-fourth grain, 
and strychnine sulph. one-thirtieth grain 
injected hvpodermically will give the 
quickest relief. When weakness and nerve 
depression occur stimulants taken in mod- 
erate doses are useful. The diet should be 
highly nutritious and easy of digestion. 
All excitement should be avoided. Locally 
all unguents, douches and fluids to be used 
with mops, or as sprays, should be free 
from irritating substances and rank odors 
unless it be necessary to remove from the 
air passages abnormal formations. A satur- 
ated solution of quinine sprayed into the 
nose three to six times daily at the begin- 
ning of the attack is useful. When the 
nasal membrane is swollen adrenalin chlor- 
ide one part to two or three thousand parts 
of a weak solution of salt sprayed into the 
nose and eyes frequently affords relief. 
Liquid alboleine, when cold and used with 
a dropper glass or nebulizer in the nose, is 
a source of much relief. Towels wrung 
out of hot water and applied to the entire 
face at short intervals helps to allay the 
distressing itching. Finally, where the use 
of cocaine is not contraindicated a four or 
six per cent, solution sprayed into the nose 
and eyes in moderation will give positive 
relief for a short time. The author has 
used Dr. Dunbar's pallantin and believes 
it does more harm than good. Those who 
cannot avail themselves of a suitable climate 
should remain as much as possible within 
doors. Where circumstances admit change 
to the seaside frequently effects speedy re- 
lief and sometimes a cure. A locality 
where the wind usually blows from the sea 
should be selected or high mountains where 
there is not much yrass and no ray weed or 
-olden rod, and where this cannot be done 
closely inhabited cities with few grassy 
squares should be preferred. 



Richmond Journal of Practice, November, 
The Value of Elimination in the Treat- 
ment of Certain Forms of Epilepsy.— 

Dr. J. H. Hodges says that in the study of 
the large majority of the cases which have 
come under his care he has been impressed 
with the toxic pathogenesis of epilepsy and 
his experience has shown that there is a 
hypertoxic underlying bases with inade- 
quate elimination. Believing that there 
was more of utility and value in it than 
could usually be obtained in intermittent 
office consultations and prescriptions, and 
wishing to test this method to the fullest 
extent he selected three children from his 
practice, two boys and one girl, all of nearly 
the same age, twelve to fourteen years, and 
sent them to his private hospital for a term 
of six weeks. So far as he was able to 
judge their average paroxysms were from 
two to four a week when not under large 
doses of bromides. The preliminary urin- 
ary examinations showed in each case an 
undue proportion of iudican in the renal 
excretion as well as a deficient excretion of 
urea. It is needless to trace the treatment 
of these cases minutely, but with the excep- 
tion of small doses of strontium bromide 
and a gradual reduction of salt in an aseptic 
diet until complete dechlorization was se- 
cured these patients had no medicines given 
except a laxative when necessary for the 
eltmination of the various products of me- 
tabolism. All of the other methods avail- 
able, however, for the purposes of elimina- 
tion were employed, such as an aseptic 
diet, free water drinking, moderate exercise 
by means of light and interesting work, 
massage and vibration, sweating by means 
of the Baruch Tonic Bath System, and 
eliminative measures by aid of the sinus- 
oidal high frequency currents, etc. The 
result was in each case the seizures were 
notably decreased and the general health 
markedly improved. The vital and resistive 
force in each patient was so much improved 
as to be readily noticed by any one and in 
the case of one of the patients, there has 
been up to this time no return of the apilep- 
tic seizures while the other two have suf- 
fered only slight inconveience at long or 
erregular internals, more of them have ex- 
ceeded fifteen graves of Stromonium 
Bromide daily, and all have continued, as 
best they could. The elemenative and 
tonic measures first prescribed. These cases 
cannot yet be classed as "cured", but their 
continued improvement after the lapse of a 
year argues well for the future. The in- 
efficiency of treatment in the past should at 
least lend credulity to the present method 
of treating some cases of epilepsy and hold 

out renewed hope for greater success in the 

The Southern Clivic, October, 1907. 

Constipation and Nervousness: — I ) r . 

W. T. Mars says the world is constipated. 
Constipation and its consequent absorption 
causes much of the nervousness extant to- 
day. Melancholia and hypochondriasis 
are more uniformly dependant upon the ab- 
sorption of toxines into the blood than any 
other cause, the condition being dependant 
upon insufficient and erregular intestinal 
elimination. Nearly all women are consti- 
pated the hysterical and neuratic doubly 
so. Every constipated woman has a pain 
in head, back and side. France is the most 
neuratic people in the world and likewise 
the most constipated inebriates, cocanee 
fiends and other dope habities are generally 
constipated. The absorption of toxic mat- 
ters creates morbid appetites and desires. 
The anemia and chorsis of young women 
usually depend upon a loaded colon and 
reeturn. "Iron for the blood" in such 
cases is misdirected therapy. The pollu- 
tion of the blood stream from constipation 
engenders habits and persersions which 
may in time become so fermly established 
as to defy their eradications. The cure for 
constipation is not in taking pergative 
pills, for they as a rule only increase the 
trouble aside from their temporary affect 
Several hundred cathartic and aperient 
drugs have been tested with a varying de- 
gree of success. Every sort of dietetic 
procedure has been tried and mechanical 
measures galore have at one time or an- 
other been put to the test. The fact re- 
mains, however, that to overcome constipa- 
tion is to overcome laziness and careless- 
ness in the time and manner of going to 
to stool. If a person will go to the closet 
at precisely the same time each day for one 
week and sit on the stool for ten minutes 
each time whether he has any incluation 
for an alinue evacuation or not he has done 
more toward correcting constipation than 
all the pills and doctors can do for him. 
He should drink water copivisly before and 
after meals. The auther has never known 
a good patron of the town pump to be trou- 
bled with constipation. 

Virginia /Medical Semi-Monthty, November, 
22nd, 1907. 
Principles of Surgery Lecture X. L. Sur- 
gical Tuberculosis Causes Symptoms 
Diagnosis Prognosis and Treatment: — 
By Dr. Stewart McGuire, Richmond, Va. 

Intabation:— j)i . P. D. Lipscomb believes 
that throretically, intubation should never 


be done except as a dernier resort. This is 
easily followed in institutional work, but in 
private practice where the conditions are 
very different, it often seems expedient to 
intubate earlier. In pre-antitoxin days, we 
are told, that there was little to be gained 

poning intubation in well marked 

: laryngeal diptheria. At present, 
the undoubted influence of antitoxin justi- 
fies waiting for stenotic symptoms before 
resorting to operation. These become quite 
marked in the second stage of the disease — 

<• of spasm — when the pseudo-mem- 
brane begins to form. The following 
symptoms may be noted; characteristic 
voice paroxysmal cough accompanied by 
cyanosis, harsh resperation, becoming 
whistling in character later. At this stage 
of stenosis all the accessory muscles of 
respiration are brought into play. Well- 
marked retraction in the supra-clavicular 
region and epigastrium exhaustion and 
failing pulse are noted. Children set up 
suddenly with livid face, anxious expres- 
sion and violent cough. The attacks recur 
at short intervals and suffocation is emmin- 
ent. Intubation should be done at once. 
This stage may last from a few hours to a 
week, during which time the patient is 
struggling against violent dyspnoea and 
overwhelming toxarinia. The two posi- 
tions in which intubation is practiced are 
sitting posture and dorsal recmnbant pos- 
ture. The authors experience in the former 
is limited to the intubation of two adults, 
both well developed men of good size. In 
his position it is practically impossible to 
hold the head still or to keep the patient 
from squirming almost out of reach. The 
dorsal position is always used at the Well- 
ard Parker Hospital, X. V. C. Before one 
attempts t<> intubate the living subject he 
should have thorough training on the cada- 
ver and even then a vast difference will be 
found in intubating a struggling, terrified 
child, where every moment lost in unsuc- 

ittempts diminishes chances of re- 

Marlyland Medical Journal^ Nov., 1907. 

A New Rectal Sign:— ]),- IL K Homl 
says that there is a condition of the large 
bowel in which, if the finger be lubricated 
and passed to its full length into the rectum 
the mucous membrane <>| the rectum will 
be found swollen in cushiony ridges, con- 
siderably narrowing the lumen of the organ. 
The swollen walls cannol be compressed by 
the finger. They an- nol inflamed not 
itive. The ridges mentioned are 
merely exaggerations of the natural folds 
of the mucous membrane. This condition 
is usually but not always attended by tight 

contraction of the lower most sphincter. 
Hemorrhoids do not usually occur; the 
folds are not hemorrhoids. The condition 
described extends doubtless throughout the 
whole extent of the large bowel. This is 
"a priovi," probable and is indicated by 
the extreme difficulty encountered in inject- 
ing enemata, especially high enemata, into 
the bowel; the difficulty and even impossi- 
bility of passing the rectal long tube; the 
inability of the cecum and adjacent bowel 
to propel its contents into the sigmoid and 
of the sigmoid to empty into the rectum. 
Water forced slowly and carefully into the 
bowel is returned by the bowel as colorless 
as when injected or contains debris of long 
retained fecal masses. Subsequent events 
show that the cecum meanwhile, has con- 
siderable quantities of retained feces in it. 
This condition is probably included in the 
clinical discription of "spastic colon" but 
the tangable cause, is acute swelling of the 
mucous membrane of the bowel. Even 
when the lowest anal sphincter is sufficient- 
ly relaxed, there remains often a sensation 
of tension in the empty rectum and the 
finger still feels the tense swollen folds of 
mucous membrane. The author believes 
that this state of affairs is often followed by 
the formation of hemorrhoids if unrelieved 
In the cecum masses of feces thus prevent- 
ed from escaping must if irratating eventu- 
ally do damage. Speculations as to the 
possible sequel in dysentary or appendicitis 
are of little value. It is worth while to 
note however that evidence obtained by 
digital examination, as already described, 
would not necessarly be set aside by that 
secured by autopsy or through operation 
under anaesthesea, in either of which con- 
ditions the swelling might have subsided 
before inspection. This may be the reason 
why in operations for appendicitis, the 
large bowel is often reported to show no 
svmptoms whatsoever of disorder when it 
could hardly be innocent of some part in 
the causation. A tense swelling which, in 
the rectum disturbs cerculation enough to 
cause piles, might surely, occuring in the 
appendix and adjacent cecum, cause ulce- 
ration in the presence of irratating bowel 

The Alabama Medical Journal, November, 


Infant Feeding:-] )r w w Betterworth 
believes that maternal feeding is beyond 
question the best food for the infant under 
one year of age; it is the food especially 
adapted to the needs of the infant; breast 
fed babies are healthier more vigorous and 
more resistant to disease than bottle fed 
babies, for while the milks of mammals 



have certain charateristics in common in 
that they contain fat sugar protieds mineral 
salts and water and while for all practical 
purposes the sugars are the same such is 
not the case with the fats and especially is 
this true of the protieds, and herein, lies 
one of our greatest difficulties, that of adopt- 
ing the protieds of cow's milk to suit the 
digestive capacity of the young child. The 
full-term baby has a premature stomach; 
time and a proper food are required for it to 
complete its physiological developement. 
The early secretion of the breast, the colo- 
strum acts as a stimulant to the digestive 
organs. This period usually lasts a week 
or ten days, and is gradually replaced by 
milk having a fairly uniform composition 
during the balance of the nursing period. 
The earliest secretion of the stomach is 
rennet, and this ferment acting upon the 
casein forms a flocculent precipitate calcium 
paracasein, which after passing into the 
intestines is digested by the pancreatic and 
intestinal secretions Hydrochlric acid is 
soon secreted which, combines with the 
calcium of the paracasien clot, forming 
free paracasein and a firmer curd results. 
This curd is now acted upon by pepsin and 
true stomach digestion is inaugerated. 
When the infant fails to make a weekly 
gain in weight or shows persistant sings of 
indigestion an analysis of the milk should 
be made. In obtaining breast milk for 
analysis the middle milk or better still all 
the milk from one breast should be secured. 
For all purposes the Babcock or Holt 
method may be used in determining the fat 
percentage. The sugar percentage varies 
very little andean be disregarded. Know- 
ing the specific gravity and the fat percent- 
age an approximate estimate of the protieds 
may be made or a Williams Scale will in- 
dicate the protied percentage. An excess 
of fats or protieds often causes digestive 
disturbances Regurgitation or vomiting of 
an acid fluid suggests an excess of the 
former while colic and stools containing 
curd indicate too high protieds, an insuf- 
ficiency in quantity or quality of the milk 
will be associated with much fussing con- 
stipation, and either a loss of weight or a 
failure to make a weeklv increase. 

The Southern Practitioner, Nov., 1907. 
Open Method of Treating Fractures: — 

Dr. D. Eve agrees with Dr. I. H. Keely, 
who states "that while it is not advisable 
or necessary to operate in all closed frac- 
tures yet there are certain bones which, 
when fractured generally demand operative 
interference if we would obtain the best 
anatonical and functional results, many 
authorities still maintain that no closed 

fracture should be converted into an open 
one, but there are some fractures in which 
even the most conservative surgeons will 
admit that, were it not for the danger of 
sepsis intervening, better functional results 
could be obtained by operation. In all 
cases in which marked communitiou of 
the fragments is present and when reduc- 
tion is impossible in oblique and spiral 
fractures of the bones of the extremities 
operative intervention is justified. Many 
of the deformities pseudoarthroses and loss 
of function seen to follow fractures will 
thus, in most instances be obviated. The 
unsightly deformities which so seriously 
destroy the usefullness of the part and pre- 
dispose to re fracture will be prevented. 
Under this heading may be included frac- 
tures in which pressure is brought to bear 
on neighboring vescera, nerves and blood 
vessels, fractures associated with disloca- 
tions, and fractures involving joints." 

By exposing the seat of fracture, the ac- 
cumulated excess of blood or effused serum 
can escape, and at the same time permit 
the removal of any soft tissues that may be 
between the ends of the bone. Further- 
more, in case of a comminuted fracture > 
the surgeon can remove loose fragments of 
bone which have become entirely separated 
from their periosteal covering. The techni- 
que after obtaining most thorough cleanli- 
ness is to make an incision large enough to 
enable the surgeon to deal effectually with 
the fragments. It should be made also in a 
location, which will make a minimum 
chance of injuring important structures and 
give easy access to the ends of the bone. The 
skin should be excluded from the wound 
by attaching sterile cloths to the cutanious 
margins by clamps. After exposing the 
fragments they should be carefully ex- 
amined and all clots and intervening 
structures removed and accurate opposition 
secured. Manipulation and extension with 
leverage may be necessary, and powerful 
forceps such as Peters may be found of 
great advantage to temporarily retain posi- 
tion while silver wire absorbable sutures 
silk-worm gut screws or clamps, etc., are 
employed to perminently maintain coapta- 
tion. If much oozing is expected a drain- 
age tube may be inserted before the wound 
is closed. An immoblizing dressing should 
then be applied to the part. 

The Southern Clinic, Nov., 1907.- 
Additional Experience With a New 
Proceedure in Operating lor Ano— Rectal 
Fistula--:By Dr. J. R. Pennington. 


The Louisevill monthly Journal, Nov., 1907. 
The Relations Between the Medical 
Profession and the People: — By Dr. II. 
II. Grant. 

Texas Medical Journal, Nov., /' 
The Moralities ol Medicine: — By I >r. C. 

M. Rosser. 

Book Notices. 

Journal of the Elisha Mitchell Scientific 
Society. Issued quarterly. Vol. XXIII, 
No. 3. Nov. 1907. Chapel Hill, N. C,. 
U.S. A. 

When Things Were Doing. By Col. 
Steere. Chicago, Chas. II. Keer & Com- 
pany, L908. 

whole field of medicine in its advanced 
state of development is required by the prog- 
ress of recentiyears is a proposition that can- 
not be gainsaid. To question it implies that 
the questioner has not kept in touch with 
the radical changes, the more elevated view- 
points, the more accurate methods and the 
the improvements in details of the practice 
which have combined to extend the scope of 
medicine and make it an exact and success- 
ful science instead of an empirical and un- 
certain art. Such an era of progress is with 
us now, and every practitioner desirous of 
maintaining his position and doing his duty 
to his patients must needs take cognizance 
or drop astern. It is fortunate for those ac- 
ively engaged in practice that they can sot 
readily gain this new knowledge combined 
and fitted in with what has been inherited 
from the past and has survived the ordeal 
of modern re-examination. This service is 
being performed for them in this work un- 
der ideal auspices, for no editor could have 
been chosen with a broader view of medi- 
cine in all its bearings than is possessed by 
Dr. Osier, nor with a keener kuoweldge of 

Modern Medicine. Its Theory and Prac- 
tice. In original Contributions by Amer- 
ican and Foreign Authors. Edited by 
William Osier, M. D., Regius Professor the best man to call upon for each coustitu- 
of Medicine in Oxford University, Eng- ent section. The phenomenal sale argues 
land; formerly Professor of Medicine in wide appreciation of the advantage of pos- 
Johns Hopkins University, Baltimore; in sessing a complete library and reference 
Oxford University of Pennsylvania, work presenting the net medicine of the new 
Philadelphia and and in McGill Univer era, disembarrassed of outworn ideas, and 
sity, Montroal. Assisted by Thos. Mc- covering the whole subject with the highest 

Crea, M. D., Associate Professor of Med- 
icine and Clinical Therapeutics in Johns 
Hopkins University, Baltimore, In sev- 
en octavo volumes of about 900 pages 
each, illustrated. Volume III, just 
ready. Price per volume: cloth, $6.00, 
net: leather, 57.<>i>, net: half-morocco, 
$7.50, net. Lea Brothers & Co., Tub, 
Ushers, Philadelphia and New York- 

The appearance of the third volume of 
( (sler's Modern Mediciae marks the steady 
progress of this great work toward comple- 

authority and practicality. 

Diseases of the Nose and Throat. By D. 
Braden Kyle, M.D., Professor of Laryn- 
cology and Rhinology, Jefferson Medical 
College, Philadelphia Fourth Edition, 
Thoroughly Revised and enlarged. Oc- 
tave volume of 725 pages, with 215 illus- 
trations, 28 in colors. Philadelphia and 
London: W. B. Saunders Company, 1907. 
Cloth, $4.00 net; Half Morocco, $5.50 
Dr. Kyle's work has undergone a thor- 

tion. In this volume the grand dicision of ough revision, many new subjects have 
is concluded, aud space been added, other subjects practically re- 
is found for equally full consideration of written, and new illustrations included. 
Diseases of the Respiatory Tract. The Among the new subjects and those rewrit- 
fourth volume, now goingthrough press, ten are: Catching Cold, Lithemic Rhinitis, 
will cover Diseases ol the Circulatory Sys- Chemic Ulcers, Lipoma of the tonsil, Fibro- 
temand Blood. The fifth will deal with myxoma of the Nasopharynx, Carcinoma of 
the whole great subject of Diseases of the the Larynx, Sarcoma of the Nose, Glioma 
Alimentary Tract. The sixth is to group of the Nose, Telangiectoma, Syphilis of the 
Diseases ol the Kidneys, those associated Septum, Angiomyxoma, and Angioma of 
with internal Secretion, those of still ob- the Septum, Bone Cysts of the Accessory 
scure causes, the Diseases of the Muscles, Sinuses, Rhinopharyngitis Mutilans, Anses- 
and Vaso-motor and Trophic Disorders, thesia of the Tonsil' Glandular Pharyngitis 
The seventh and final volume completes the Lateralis, Vincent's Angina, Angina Ulcer- 
entire subject by covering Nervous and osa, Benigna, Cyanotic Pharyngitis, Angi- 
Mental Diseases. The conveniences of this oneurotic Edema, Pharyngeal Aneurism, 
grouping is manifest. Cough, Purpura Hemmorrhagica, Congeni- 

That an authorative work presenting the tal Stridor, Scleroma of the Larynx, Bron- 



choscopy, Voice and Speech defects and 
Functional Aphonia, is precisely up to date 
in every way. 

Atlas and Text-book Human Anatomy. 
Volume III, completing the work. By 
Prof. J. Sabotta, of Wurzburg. Edited, 
with additions, by J. Play fair, McMur- 
rich, A. M., Ph.D., Professor of Anatomy 
at the University of Torontou, Canada. 
Quarto of 342 pages, pages containing 
297 illustrations, mostly all in colors. 
Philadelphia and Loudon: W. B. Saun- 
ders Company, 1907. Cloth, $6.00 net; 
Half Morocco, $7.50 net. 
This volume completes the work consist- 
ing of three most useful and attractive 
volumes by one of the world's most distin- 
guished anatomists. The fact also that Dr. 
McMurrich has edited this American edi- 
ditiou adds to its value. Volume III in- 
cludes a part of the vascular system, the 
entire nervous system and the organs of spe- 
cial sense. The peripheal nerves and ves- 
sels are depicted, as the dissector sees them, 
together in the same region. The illustra- 
tions are in color and they are most accu- 
rate. The student will find these atlases 
most useful in the dissecting room where 
upon a single page will be shown the great 
majority of the structures in a single layer 
of the dissection. 

To the medical Student and physician 
the work will prove most helpful since it 
includes what will be helpful and excludes 
too great minuteness of detail which would 
prove confusing rather than instructive. 

The great wealth of the lithographers art 
as shown in these pages has not been sur- 
passed. As an example of the bookmak- 
ers skill the work is a credit to the 

The Treatment of Fractures. With Notes 
Upon a Few Common Dislocations. By 
By Chas. L. Sc udder, M. D., Surgeon to 
the Massachusetts General Hospital. 
The new (6th) Edition, Enlarged. Oc- 
tavo volume of 635 pages, with S54 origi- 
nal illustrations. Philadelphia and Lon- 
don: W. B. Saunders Company, 1907. 
Polished Buckram, $5.50, net; Half Mo- 
rocco, $7.00 net. 

Over 25,000 copies of this remarkable 
work have been sold, and the advance 
orders for this new sixth edition indicate 
that Dr. Scudder's work is destined to break 
all records in the medical publishing field. 
This edition has been carefully revised and 
much new matter added. Especial atten- 
tion has been directed to obstetric skull 
fractures of the newborn; to fractures of the 
zygoma, of the malar bone, of the superior 
maxilla, of the head and neck of the radiusl 
of the neck of the femur, and the carpa, 

scaphoid; to unreduced dislocations of the 
elbow; to acromioclavicular dislocations; 
to pathologic fractures; to old fractures of 
radius, and to Volkmann's contracture. 
Over one hundred new illustrations have 
been added. Scudder's Treatment of Frac- 
tures is coming to be the standard of excel- 
lence in America. 

The Principles and Practices of Modern 
Oltology. By John F. Barnhill, M.D., 
Professor of Otology, Laryngolgy, and 
Rhinology, Indiana University School of 
Medicine; and Ernest de W. Wales, B.S., 
M.D., Associate Professor of Otology and 
Rhinology, Indiana University School of 
Medicine. Octavo of 575 pages, with 305 
original illnstrations. W. B. Saunders 
Company, 1907. Cloth, $5.50 net; Half 
Morocco, $7.00 net. 

The very latest authority on the sublect 
of diseases of the ear. The objects of the 
authors are clearly stated as follows: (1) to 
modernize the subject; (2) to correct cer- 
tain traditional beliefs; (3) to advocate the 
earliest possible prophylaxis and treatment; 
(4) to emphasize the importance of a thor- 
ough examination and a definite diagnosis 
as a basis for rational treatment; (5) to 
thoroughly illustrate the text. How well 
they have succeeded is perfectly evident to 
the reader. The work is a clear and con- 
cise discussion of the subject. 

The authors, in writing this work, kept 
ever in mind the needs of the physician en- 
gaged in general practice. It shows the 
results of personal experience as practition- 
ers and teachers. Much space is devoted 
to prophylaxis, diagnosis, and treatment, 
both medical and surgical. Great pains 
have been taken with the illustrations' 
which are as practical and helpful as it is 
possible to make them, and at the same 
time they are highly artistic. A large num- 
ber represent the best work of Mr. H. F. 
Aiken. It is the latest work on the subject. 

Sexual Instinct. — Its Use and Dangers as 
Affecting Heredity and Morals. By 
James Foster Scott, A.B. (Yale) M.D., 
CM. (Edinburgh). Late obstetrician to 
Columbia Hospital for Women, and Ly- 
ng-in Asylum, Washington, D. C; late 
Vice-President of the Medical Associa- 
tion of the District of Columbia, etc., etc. 
2nd Edition, Revised and enlarged. 8vo. 
474 pages, 111. Cloth, Postpaid, $3.00. 
E. B. Treat & Co., Publishers, 242-243 
West 23rd Street, New York. 
A large part of the guidance of human 
conduct belongs to the medical profession. 
By teaching the laws of preventive medi- 
cine, of hygiene, of quarantine and by 
pointing out the need of bodily cleanliness, 


and the danger of filthiuess and dissipation 
and vicious or careless modes of life the 
physician exerts a powerful influence. 
Those who have been educated concerning 
their customs, amusements, and general 
rules of life cannot stray far from the path 
of right. 

This work by Dr. Scott is unique. He 
deals with a subject which requires skillful 
treatment and he has accomplished this end 
in a manner which can give offense to 
none. The book should be read by every 
doctor; it will give to him points of view 
that cannot fail to help him in teaching the 
masses. If he succeeds in but an isolated 
instance, because of the help acquired 
through Dr. Scott's book, it means that 
some good has been accomplished. 

The demand for a second edition of such 
a work is evidence of the esteem in which 
it is held. If it could be placed in the 
hands of every man in America a marvel- 
ous change must soon be seen in human 

Empire Builders. By Francis Lynde. With 
illustrations by Jay Ilambridge. In- 
dianapolis. The Bobbs-Merrell Co. 
A very readable book whose hero is a far- 
seeing, big-hearted, irrepressible young son 
of the west, who hits upon a gigantic rail- 
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handed, in spite of the desperate opposition 
of a strong ring of capitalists and politi- 
cians whom his success will ruin. The sto- 
ry of how he accomplishes all this, builds 
up a fortune and wins the railroads presi- 
dent's niece for a wife, makes a strong story 
although one could almost wish that part 
of the story had been omitted. The simple 
story of the fight for the right is quite 

Maternity. A book for the lay reader, the 
medical student, the trained nurse. By 
Henry D. Fry, M.D., Sc.D. 12 mo. 
cloth; Price $1.50 net; postage, 10 cents. 
The Xeale Publishing Co. New York 
and Washington. 

Dr. Fry has written a book that will 
eliminate ignorance. "Maternity" is a 
needed book, a valuable book, one that will 
bring com tort and help to mothers and to 
women who are looking forward to ap- 
proaching motherhood with all the dread of 
ignorance, the utter helplessness of fear. 
[n other words, Dr. Fry's book will dissi- 
pate darkness by increasing light. It will 
enable expectant mothers to think of child- 
bearing, not with apprehension and pain, 
the unspeakable mental distress that too 
many of them now suffer, but with the 
beautiful assurance of knowledge. 

The Race for the Emporer's Cup, By Paul 

Eve Stevenson. With illustrations. New 
York. The Rudder Publishing Compa- 
ny. 1907. 

A description of the race across the At- 
lantic for a cup, whose donor is no less a 
person than the Kniperor of Germany, and 
of the boats which engaged in the contest. 
Well written certainly and doubtless vastly 
interesting to the yachtmen, but to the 
landsmen of more or less questionable 

The Mind of the Master, or The Nervous 
of Jesus. By Salvarona, Associate of the 
American Institute for Scientiffc research. 
Illustrated; 12 mo.; 100 pages. Paper, 
50c. net. Cloth, Gold Title, $1.55 net, 
by mail. Postage 5c. Publishers' Trade, 
pap. 42c. Henry G. Walters, Publish- 
er, Langhorne. Bucks, Co., Pa. 

The Physician's Visiting List for 1908. 

Fifty-seventh year of its publication. P. 

Blakinton's Son & Co., Philadelphia, Pa. 

Price $1.00. 

Lindsay & Blakiston's Physicians Visit- 
ing List is too well known to doctors to re- 
quire any detailed description. It is one of 
the best and most convenient. Containing 
data in concisely accurate form, it is valu- 
able as a pocket cempanion. The Dose- 
table has been revised in accordance with 
the New Pharmacopoeia. 

Anarchism & Socialism. By Geo. Plechan- 
off. Translated with the permission of 
the author by Eleanor Marx Aveling. 
With an introduction by Robert Rives 
LaMonte. Charles H. Kerr & Co., Chi- 
cago. 1908. 

The Reublic. By N. P. Anderson. Chas. 

H. Kerr & Co., Chicago. 1908. 

A dialogue discussion of social and eco- 
nomic problems from the Socialist's stand- 

Marxian Economics. By Euterest Unter- 
mann. Chas. II. Kerr & Co., Chicago. 

An introduction to the work by the great 
Socialist, Marx, on "Capital." 
Merck's 1907 Index. Third edition. An 
Encyclopedia for the Chemist, Pharma- 
cist and Physician. Octavo, pp. 472, 
Merck & Co., New York. 
This book gives the names and synonyms, 
source of origin, chemical nature and for- 
mulas, physical form, appearance and prop- 
erties, melting and boiling points, solubles, 
specific gravities and methods of testing, 
therapeutic uses, modes of administration 
application, ordinary and maximum doses, 
incompatibles, antidotes, special cautions, 
hints on keeping, handling, etc., of the 



chemicals and drugs, used in chemistry, 
medicine and the arts. 

S The crude drugs of commerce, have been 
added and under each drug are indicated 
the poses of the extracts, tinctures, etc., 
as iu previous editions. Specific gravities 
are given at 15 degrees C. and in many 
cases, following the U. S. Pharmacoepia, 
they are also at 25 degrees C. 

As the index is not intended to be a price 
list, no prices are given, but instead, com- 
parative values are stated for convenience. 

A valuable book for constant use for 
every practitioner. 

Willcome's Excerpta Therapeuta. Bur- 
roughs Willcome & Co., London, New 
York, Montreal, Sidney, Cape Town. 
Containing a list of the valuable drugs 
and preparations made by this very reliable 
firm. A convenient and handy vade mecum 
with a list of diseases and indications for 
treatment, diet tables, etc. 

International Clinics. A quarterly of Illus- 
trated Clinical Lectures and especially 
prepared original articles on Treatment. 
Neurology, Pediatrics, Obstetrics, Gyne- 
cology, Orthopaedics, Pathology. Derma- 
tology, Ophthalmology, Otology, Rhiuol- 
ogy, Laryngology, Hygiene, and other 
topics of interest to students and practi- 
tioners. Vol. IV, Seventeenth Series, 
1907. Edited by W. T. Longcope, M.D., 
Philadelphia, U. S. A. J. B. Lippincott 
& Co., Philadelphia and London. 
Every issue of this Quarterly is brimful of 
interest. The articles are selected from the 
best work of the whole world by men who 
are capable of disciimination in the matter 
of excellence. Comment is scarcely neces- 
sary since the International Clinics are 
known so widely. 

Transactions of the Indiana State Medical 
Association. Fifty-eighth annual session 
held at Indianapolis. May 22-24. 1907. 
Dr. A. W. Brayton, Indianapolis, Sec- 

Squibb's Materia Medica. 1908 Price List. 
OPublished by E. R. Squibbs & Sons. 
ONew York. Brooklyn. 
'"-■A complete alphabetical List of the pro- 
ducts of the house of Squibb, embracing 
the articles in the U. S. Pharmacopoeia 
and the National Formulary, together with 
the non-official chemicals, Pharmaceuticals, 
Tablets and newer remedies in general use. 
It sets forth their origin, Latin and 
English titles, Synonyms, Physical and 
Chemical characteristics, incompatibles, 
antidotes, therapeutic indications, doses, 

Abstracts of the Leading articles 
of the month. 

The Diagnosis of Chronic Valvular Disease 
of the Heart. 

Carr, the Practitioner, includes in his 
study only the lesions of aortic and mitral 
valves. The first step is to recognize ob- 
struction or incompetence or both atlone or 
more of the orifices. Next one must see 
which valve or valves are affected, the mur- 
mur, the time in the cardiac cycle, the place 
where best heard, the lines of conduction. 
Next the cause must be investigated, 
whether it be rheumatic or degenerative, 
and in aortic cases whether it is of syphil- 
itic origin. Next one must determine the 
extent to which the affected valve is dam- 
aged, this being mainly determined by the 
amount of enlargement to which the vavu- 
lar lesion has given rise. Next one must 
find out whether the lesion is properly com- 
pensated, only precautionary measures be- 
ing necessary as long as compensation is 
satisfac tory. Accuracy in diagnosis is 
chiefly necessary for purposes of prognosis 
and treatment, and only when the foregoing 
data have been determined can the latter be 
successfully carried out. 

Inguinal Hernia In Children. 

Clogg, (the Practitoner, ) has not ob- 
served a case of direct hernia in 
children. The indirect he divides broadly 
into the congenital and the acquired accord - 
infi to the aetiology of the sac. The repeat- 
ed investigations of the interior of the sac 
has led the author to believe that the cause 
of hernia is an attempt on the part of Na- 
ture to obliterate a congenital processus 
vaginalis, that is, the sac in hernia is of 
congenital origin, in children, quite apart 
from the age of the child. The author's 
classification of hernia in children includes 
(1) sacs which consist of the whole of the 
processus vaginalis, total funicular sacs. 
If these conditions are due to a congenital 
sac, they can only be cured by the removal 
of the sac. A truss is unlikely ro produce 
any change in the sac. The only cure for 
hernia which has been seen after the first 
few weeks of life is by operation, and the 
earlier the operation is performed, the bet- 
ter, after a child has been weaned. Indica- 
sions for operating earlier than this are (1) 
strangulation, (2) two or. three attempts at 
strangulation with difficult reduction, (3) 
large hernia, especially caecal hernia, 
which cannot be prevented by a truss from 

The Resetioa of Large Nerve Trunks 
W thoui Paralysis. — Roeder ( Deutsche 
Medizinische \Yochenschrift) savs that a 



number of instances have been reported in 
which the resection of peripheral nerve 
trunks has not been followed by the usual 
sequelae. As cases of this sort are still 
very rare, it is advisable to collect all the 
evidence possible bearing on the subject. 
So far there is no satisfactory explanation 
of the occurrence. It has been suggested 
that, somewhat as is the case with the 
blood-vessels, collaterals may form and take 
up the function of divided nerves. Gold- 
man believes that in cases in which tne con- 
tinuity of the nerves has been destroyed by 
neuromas, the damage to the nerve was 
congenital and was compensated for during 
intrauterine life by the development of new 
branches bridging the gap due to the neo- 
plasm. In the author's own case two neu- 
romas wero removed from the upper arm 
and shoulder of a young woman. In order 
to extirpate the the tumor in the former sit- 
uation it was necessary to resect a portion 
of the ulnar nerve with which it was inti- 
mately related. It was expected that paral- 
ysis would follow, and the distal end of the 
was grafted into the median nerve trunk, 
but the next day on removing the dressing 
it was found that the patient had perfect 
control of the extremity. A year later an- 
other similar but much larger growth was 
removed from the pelvis and in so doing the 
anterior crural nerve had to be sacrificed. 
Here again no impairment of function fol- 
lowed and the patient while recovering 
from the anaesthetic moved the member in 
all directions. A similar observation was 
made in connection with the removal of a 
smallei growth in the neck, involving the 
spinal accessory nerve. 

Medical Egotism. 

We desire to call attention, for the pur- 
pose of severely condemning it, to a highly 
objectionable feature that appears to be in- 
ommon in the writing of med- 
ical men, particularly of those who write 
from a clinical standpoint, namely, the 
habit of blatantly extolling their own suc- 
cess in diagnosing or treating a case in con- 
trast with the reputed failure of some other 
man or men. To be sure the vaunt is usu- 
ally hidden behind the ostensible enthusi- 
asm if the writer for some special method, 
or drug, or theory, but the egotism is very 
thinly veiled. To judge from the style or 
the contributors to medical litera- 
ture, all that ever went before them in the 
handling of the particular subject in ques- 
tion were fools and ignoramuses. They in- 
dulge in a specially luxuriant cud-chewing 
■n assertion that the case was 
wrongly or unsuccessfully dealt with by 
some physician or surgeon of prominence 
efbore coming under their effective care. 

"This patient had previously been under 
the care of two eminent specialists, one of 
them a professor in one of our leading 
schools of medicine." "During several 
years of his sickness different physicians 
had treated the patient for heart disease. 
My records show that after five treatments 
under my method for gastritis he was com- 
pletely relieved of his heart disease." 
Such are examples of the objectionable 
practice referred to. It is as gratuitous as 
it is objectionable. No useful purpose is 
served by it. It adds nothing to the real 
scientific value of the observation, or the 
method, or the prescription, or whatever it 
is that is being reported, that the patient 
had previously been treated without success 
by a professor in college, even if the state- 
ment were true — it is usually based entirely 
on the garrulous gossip of the patients 
themselves, who are notorious fabricators 
in regard to their ills and experiences. If 
the plan of procedure or the agency of the 
cure advocated possesses any genuine in- 
trinsic merit this will sufficiently appear 
upon a plain statment of the facts; and if 
there be any credit due to the demonstrator 
in virtue of his initiative in the matter, that 
will also be far more effectively compassed 
by a calm and dignified narration of the 

Of all the elements in the character and 
modus operandi of charlatanrylin medicine, 
none is more offensive than the blatant 
egotism that is expressed in the sentence 
which in substance if not in so many words, 
invariably forms the culmination of the 
quack's highly colored advertisement, "Af- 
ter all others have failed, comeand see me." 
The secret of its peculiar offeusiveness is 
akin to that which makes the appeal to 
passion so disgusting; it is human nature 
run hideously to seed. It represents an in- 
tegral part of the quack's knowledge of hu- 
man knowledge, and his base play upon it. 

It is natural, and, to a certain extent, 
laudable, for a man to believe in himself, 
and especially when he thinks he has dis- 
covered or worked out a superior method of 
action to confidently proclaim and hold it 
against the seeming contradictious of for- 
mer experience. Not only is it natural and 
praiseworthy for a man to believe in him- 
self, but the public has faith in the man 
who has faith in himself. The quack, re- 
alizing those qualities of human nature, and 
knowing that with the ignorant one cannot 
lay the colors on too thickly, purposely 
overdoes the thing. Kveryone else but he, 
in his line of work, is a conventional ass; 
he is the only original and intelligent path- 
finder who has had the daring and acumen 
to strike a new and direct way. "When 
all others have failed, come to me." 



This kind of a spirit has always been 
held, and rightly held, the prime her- 
esy of science, and peculiarly of medical 
science, whose nature and motif consist in 
the service of weakness and suffering-. Its 
repudiation, together with the criminality 
of creating a demand for medical service, 
forms the groundwork of the strong code 
which prevails against advertising by med- 
cal men. There is no more excuse for the 
exhibition of such egotism in the promul- 
gation of new knowledge to the profession 
itself than in the physician's dealing with 
the public. There is no place in medical 
science for the covert sneer at another 
man's opinions of or practice, or for the ex- 
ploitation of an "exaggerated ego." We 
care not whom our shaft may chance to hit 
in this matter. The greater the offender, 
the more reprehensible the offense. As a 
matter of fact, however, we are bound to 
say that the big men are not as a rule the 
perpetrators of this particular crime, albeit 
there are some prominent lights of the pro- 
fession who are habitually guilty. Of all 
men the scientist shold be of humble mind 
and a modest spirit. If his discoveries and 
theories are of the truth, they will prevail. 
They will not the more strongly prevail be- 
cause he bolsters them up with petty egot- 
ism and uncalled for discredit of others. 
The intrinsic and enduring value of a man's 
work is tha only legitimute door to merit 
and honor; all that climb up some other 
way, the same are thieves and robbers. — 
Medical Standard. 

Blood Pressure In Fevers. 

Davidson (Lancet) has made a study of 
this subject. In scarlatina he found that 
the blood pressure curve very similar to 
those of the pulse and temperature. In 
general it continued to fall until the seventh 
or eighth day of the disease, at which time 
it usually passed below the normal line. In 
about 5 per cent, of the cases it remained 
normal throughout the entire disease. In 
the severe cases of scarlatina of the angi- 
nose type, the pressure fell as the toxemia 
increased, in spite of cardiac stimulation. 
In scarlatinal nephritis the blood pressure 
is raised during the period of albuminuria. 
The rise often occurs before the albumin 
appears. In diphtheria a reduction was 
found in every case depending largely if 
not entirely on the degree of toxemia. In 
antitoxin injections a rise appeared in tem- 
perature four or five hours after injecton, 
but the vascular pressure was found in 
almost every case to be either reduced or 
the same. In general this reduction ap- 
peared in a few minutes and passed off 
within an hour. In typhoid fever the blood 
pressure is always considerably lowered, 

the dimunition progressing steadily the 
longer the longer the continuation of the 
case, and it rises again only on the estab- 
lishment of convalescence or the occurrence 
of some acute inflammatory complication. 
In all all such operations it is evident that 
we must carefully distinguish the changes 
attributable to the fever itself from those 
which are merely secondary to the pyrexia. 

A Case of Land Scurvy. 

The .Lancet reports the case of a woman 
in whom the malady occurred after she had 
been for a prolonged period, an inpatient 
of a hospital and as a complication of fis- 
tula in ano. She was admitted to the hos- 
pital with an unhealed fistula wound with 
a copious purulent discharge. A first opera- 
tive attempt was made to clear the wound 
but its progress toward healing was unsat- 
isfactory and in a few weeks she began to 
have sore mouth, swollen gums, intermit- 
tent fever, bleeding from the gums, and 
from the rectal wound, purpuric rash, etc. 
She was at once put on an anti-scorbutic 
diet (in addition to indicated medical meas- 
ures) and began to improve in every way. 
Associated with this general bettesment, the 
wound condition improved, the separative 
power of the tissues increased, and in the 
course of a few weeks she was able to leave 
the hospital, if not cured, at least very 
considerably improved. The author notes 
three points of interest in the case. (1) 
The occurrence of scurvy in a patient whose 
food had been the same as customary among 
people of her class, for on special inquiry 
she stated that she was in the habit of tak- 
ing plenty of good and fresh food. More- 
over, she had been in hospital a month, 
where her diet was a plentiful one of milk, 
beef-tea. custard, jelly, and so on, before 
the onset of tha scorbutic symptoms. (2) 
The possibility of the retardation of healing 
seen in certain forms of long standing 
"callous" wounds beiag due to a scorbutic 
diathesis. (3) The possibility of the long- 
continued suppuration and mental distress 
being the cause of this diathesis, a vicious 
circle thus being produced. 

An Operation For Embolus. 

Handley (British Medical Journal Sep- 
tember 1907.) reports an attempted re- 
moval by operation of an embolus lodged at 
the bifurcation of the abdominal aorta. 
There are was a temporary restoration of 
the blood current in the femoral artery. 
The author regards the case as one of those 
pioneer failures on which ultimate success 
so often rests. His patient was a man of 
sixty-five years, in whom the embolism 
followed an operation for hernia. He had 
but little atheroma, but was emphysema- 
tous and extremely gouty. Thirty-six hours 



after operation the whole limb was cold and whole length of the superficial femoral ar- 

no pulse could be found in the common fe- tery, and almost as far as the bifurcation of 

moral artery. A vertical incision three the popliteal. Unfortunately the general 

inches long was made over the left common condition of the patient, desperate to begin 

femoral artery with its center at the origin with, forbade further persistence. The ca- 

of the profunda femoris. The external theter was withdrawn, and the divided 

circumflex branch of the profunda was ex- branch of the politeal was ligatured. On 

posed, ligatured, and divided transversely removal of compression from the common 

on the proximal side of the ligature. No femoral no blood flowed, and it was evident 

blading occurred — a fact of ill omen, since that the obstruction higher up had only 

U showed that secondary thrombosis of the been partially and temporarily displaced. 

arteries of the limb had oceurred below the Had the patient's condition allowed the 

point of obstruction. A flexible tube about surgeon should have attempted to pass long 

the size of a Xo. 4. catheter was passed up- crocodile forceps up to the bifurcation of 

wards through the divided proximal end of the arota, to seize the clot, and to drag it 

the circumflex artery into the common fe- out, a proceeding which is certainly prac- 

moral artery. The end of the tube was 
connected to an aspirator, and some soft 
blood clot was sucked up into the tube. 
No blood flowed, and the tube was with- 
drawn. It was decided to attempt to dis- 
lodge the obstruction by a stream of saline 

ticable. Under the circumstances, the di- 
vided ends of the profunda were tied off, 
and the skin divisions sutured. The patient 
died twenty-four hours later in a typhoid 
condition, with commencing gangrene of 
the limb. At the autopsy, the left auricle 

solution. In order to obtain better access contained a shred of ante-mortem clot in 
and a freer reflux, it seemed necessary to one of its recesses. The orifice of the left 
divide as large an artery as was compatible common iliac artery was blocked by a de- 
with the subsequent maintenance of nutri- colorized and adherent mass of clot which 
tion in the limb. The profunda femoris exhibited transverse markings apparently 
was, therefore, divided at its origin and its corresponding to the musculi pectinati of 
distal end ligatured. The abdominal aorta the auricular appendix. The clot projected 
was compressed at the level of the umbili- some little distance into the abdominal aor- 
cus through the abdominal wall, so as to ta. Below it the arteries were filled by soft, 
safeguard the right common iliac from the non- adherent clot. The rest of the post- 
obstruction. A Kelly's ureteral catheter was mortem appearauces not be detailed. The 
now introduced the divided proximal end The herniated intestine had retained its vi- 
of of the profunda artery. It was cautious- tality, but the lower part of the large intes- 
ly passed upwards along the common fe- tine was intensely congested and its vessels 
moral, the external iliac, and the common were filled by ante-mortem thrombus. Ev- 
iliac artery until, as judged by previous idently one or more emboli had lodged in 
measurements on the skin, it had reached the arteries of the portion of the gut. 
the bifurcation of the abdominal aorta. A 
forcible stream of saline was sent through A Case of Cerebellar Hamorrhafte. 

the catheter, and returned freely through Ingalis and Fen wick (British Med. Jour- 
the divided end of the profunda. The point nal) report the case of a wo- 
ol the catheter was moved about within the man of twenty-six years who was admitted 
artery, so as to detach the clot within it. to the hospital in a semiconscious condition. 
Some fragments of recent clot escaped, but She had a recent numbness over the left 
relaxation of pressure on the abdominal lower face, sloght headaches, and occasion- 
aorta was not followed by a jet of blood, al giddiness. She imwroved but a few days 
arota was again compressed, and the later became semi-conscious and was sent 
washing out process was continued. Re- to hospital. Speech was then uniutelligle. 
taxation of the pressure on the arota was She swallowed slowly, had no fever, aural 
now followed by the escape through the di- discharge, was not deaf, could protude her 
vided profunda of a forcible pulsating tongue, and had normal pupils. The right 
stream of bright red blood. An attempt patellar reflex was exaggerated, the left 
wasnexl made to clean the lumen of the normal. There was no ankle clonus and 
:rficial femoral artery. The common no rigidity of the head. The left arm and 
Femoral artery was compressed. A small leg were partially paralyzed, but there 
incision was made over the popliteal artery, were no twitchings or convulsions. Urine 
and one of its branches was divided so as to was normal. Three days later, slight left 
provide a point of outflow for the saline so- ptosis was noted, the pupils became & widely 
lution with which the operator proposed to dilated' insensitive in the left, and sluggish 
flush out the artery from above. The ca- in the right. Left arm could not be moved- 
theter was passed easily in from the divided IA curious habit of shaking the bed as if in 
end of the profunda downward along the|play came on. On the fifth day after ad- 



mission she was in the same semi-conscious 
condition. Babinski's sign was well marked 
and breathing was stertorous. The head and 
eyes were turned to the right. Three days 
later Cheyue-Stokes respiration, asthenia, 
rising temperature, and rapid pulse were 
noted. She died eight days after admis- 
sion. Autopsy showed that the surface of 
the braiu was deeply congested, but there 
were no adhesions between the pia and dura 
mater. The dura mater was adherent to 
the skull-cap. At the base of the skull the 
meninges were densely adherent, especially 
in the middle fossa. On removing the brain 
a small clear cyst, the size of a split pea, 
was seen lying at the posterior extremity of 
the pons on the right side, overlapped by 
the cerebellum. They had no apparent 
connection with any deeper structure, as it 
was removed at a touch. The brain was 
normal except for general congestion, but 
in the right side of the cerebellum a cavity 
about one inch in length, which would just 
admit the tip of the little finger was found. 
This cavity was filled with old blood clot 
adherent to the walls of the cavity. The 
brain tissue over this area was extremely 
friable. No terombosis or embolism was 
found, and we could not detect any disease 
of the vessels. The author summarises some 
of the previously reported cases similar to 
their own. 

Indlcotlons for Rupture of the Membranes 

Rudaux ( La Clinique) points out that 
the bag of waters is the most important 
agent in the dilatation of the cervix uteri, 
and should be kept intact, whether the 
head is engaged or not, so long as the con- 
tractions are normal and the dilatation in- 
complete. Therefore, when making a 
vaginal examination during a uterine con- 
traction, the finger must not be allowed to 
press upon the membranes whilst they are 
tense, as there is a risk of causing prema- 
ture rupture. Further, it is to be noticed 
that this tension of the membranes is ap- 
parent before the patient experiences the 
pain oi the contraction, and calls attention 
to it. There are a variety of cases in which 
a rupture should be effected before the 
completion of dilatation. When the uterus 
is abnormally developed, either by excess 
of amniotic fluid, or by a multiple pregn- 
ancy, or by a very large fetus, it may hap- 
pen that dilatation which has been pro- 
gressing favorably becomes stationary, 
whilst the contractions continue or cease 
altogether. Under these circumstances, 
rupture of the membranes will cause the 
labor to resume its usual course. 

When permanent tension of the mem- 
branes is diagnosed, the same indication 
exists, and the same result follows. In 

such cases there is no protrusion of the sac, 
the presenting part is well engaged in the 
pelvis, and the membranes are often very 
adherent to the lower uterine wall. The 
sac does not fulfill its physiological func- 
tion, and prevents the fetal head, for the 
presentation is nearly always a vertex, 
from supplying its place. 

Early rupture is advisable when the 
presentation has a tendency to displace- 
ment and is liable to become transverse, 
also after version by external manipulation 
when it is difficult to keep the fetus in the 
desired position. Unless the membranes 
are ruptured a prolapse of the cord can 
hardly be successfully dealt with, the funis 
must be carefully replaced behind the pre- 
senting part, which then descends, and 
further danger is avoided. 

The most immediate indication for rup- 
ture is hemorrhage due to a placenta previa. 
If a large rent is made in the membranes 
they will cease to pull upon the placenta, 
and the additional pressure of the descend- 
ing part will stop the bleeding. There 
should be no hesitation in rupturing when 
the condition of the mother or child calls 
for a speedy termination of the labor. In- 
tervention is often required in twin preg- 
nancies, since the second ovum may re- 
main intact, the uterus being too much ex- 
hausted to overcome the resistance of sac. 
When the sac does not rupture with strong 
contractions and after the completion of 
dilatation, there is no reason to wait. It is 
in the interest of both mother and child to 
bring labor to an end as soon as possible. 
Waiting favors a dissociation of the amn- 
ion and chorion, and may produce retention 
of the membranes during delivery. 

Attempted Induction of Abortion by In- 
trauterine Injection of Fehllnfc's Solution. 

Tantzcher (Zentralbl. f. inn. Med.) 
states that a nurse, after missing two men- 
strual periods, attempted to induce abor- 
tion by the intrauterine injection of Fehl- 
iug's solution. The syringe used was of 
I-gram capacity, and was fitted with a noz- 
zle suitable for urethral injections of co- 
caine. Shortly after the injection she was 
seized with severe abdominal pain and re- 
peated vomiting. About midnight — fifteen 
minutes after the injection — the pulse was 
52 and irregular. The pain became worse, 
and the patient was in constant dread. The 
cardiac sounds were faint and separated by 
distinct intervals, but were othhrwise nor- 
mal. Respiration was unaffected. The 
skin was cool. The pulse became more 
regular after hypodermic injections of cam- 
phor and morphine, but remained infre- 
quent — 48 to 52. The temperatvre was 
subnormal. At I a. m. undigested, slimy, 
brownish masses of rice were vomited. 


There was no uterine hemorrhage. At 3 
a. in. the pulse had almost regained its 
normal regularity, but was still infrequent. 
At 3:30 it was o4, at 5:30, 86; the tempera- 
ture had risen to ( »7.7 1-. Later in the 
morning a slight hemorrhagic discharge 
from the vagina occurred. The urine con- 
tained red and white blood corpuscles, and 
renal, ureteral, and vesical epithelium. 
There was slight smarting on micturition; 
no casts were present. The quantity of 
urine was at first normal, but on the fourth 
day was reduced to lo'j oz. Latter the 
amount again became normal, and on the 
fifth day the previously hemorrhagic urine 
regained its normal appearance. There 
then a few leucocytes and some renal and 
ureteral epithelium, but no red corpuscles. 
A number of hyaline casts were found. On 
the tenth day the urine was normal in every 
respect. The acuteness of the onset of 
symptoms was somewhat alarming, but 
otherwise the patient was never in danger, 
and recovered rapidly. Nothing but a few 
clots were found in the vaginal discharge, 
and it could not be determined whether 
pregnancy had been interrupted. When 
the patient was discharged from hospital 
the size of the uterus corresponded to that 
of a two mouths' pregnancy. 

The symptoms of poisoning by solutions 
of salts of copper are said to be cauteriza- 
tion of the buccal mvcosa> salivation, tym- 
panites, green vomit, and brownish-red 
watery stools. The pulse is small and the 
skin cold. In severe cases these symptoms 
may be followed by jaundice, paresis of the 
limbs, and collapse. Most of the copper is 
excreted by the liver, but, according to v. 
Jaksch, the kidneys almost always present 
signs of toxic nephritis. The fatal dose of 
copper, when taken per os, is said to be 
15 I grains to 184 grains of the acetate and 
154 grains to 308 grains of the sulphate, 
though Hoffmann states that less than 10 
grains of the sulphate may produce symp- 
toms of poisoning. In this case less than 
one-twentieth of this amount produced 
alarming symptoms, I gram (about 17 
minims! of Fehling's solution containing 
0.034 gram, orslightly more than '_• grain, 
of copper. Evidently intrauterine injections 
in animals, which are followed by toxic 
nephritis. The urine becomes scanty, and 
usually contains albumin, and frequently 
blood, [n animals paresis of the limbs is 
one of the niosi prominent symptoms. 
Whether this was present in this case could 
not be determined. 

Acute I oi-sIimi of Both I .i llopla n Tubes. 

Michel (Compels rendus de la Soc. 
d'Obstet., de Gyn. et de Fediatr. de Paris) 

reports that a married woman, aged thirty- 

five, twice pregnant, and without any his- 
tory of pelvic disease, was seized with vio- 
lent hypogastric pains a few days after a 
regular period. They remained very in- 
tense for a few hours, and the patient felt 
faint. Acute appendicitis was diagnosed, 
the pains subsided, and the patient was 
able to attend to housework, when a second 
attack of acute pain occurred within six 
weeks. Michel detected a swelling in the 
right iliac fossa, and another occupying 
left and posterior fornix. He was inclined 
to believe that the masses represented re- 
trouterine hematocele, recurrent, as is often 
the case, and it happened that profuse 
menorrhagia accompanied the second at- 
tack, increasing his suspicions. Abdo- 
minal section was undertaken in preference 
to colpotomy. The swellings proved to be 
dilated and obstructed tubes — the right, 
twisted four turns, was thinwalled and con- 
tained clear fluid; the left, twisted three 
turns, was thicker and contained blood. 
There was no evidence of tubal gestation; 
the primary condition was, without doubt, 
salpingitis. The right ovary was involved 
in the torsion of the corresponding tube. 
Michel amputated the uterus above the 
cervix, taking away the diseased append- 
ages without detaching them from the 
cornua. The patient, when convalescent, 
declared that the pains had completely 
passed away. 

Right-Angled Contraction oi tho Ten- 
don Achilles as a Cause ol Stumbling, 
Etc., in Children.- iub by (Brit. Jl. of 
Children's Dis.) says the clinical picture 
presents the following variations: (1) 
Pain in the calves and round the knees. 
The child becomes tired in walking, and 
stumbles and falls on attempting to run. 
(2) Shambling gait, short steps and bent 
knees, the bending being increased on tak- 
ing longer steps. (3) Constant occurrence 
of sprained ankle. (4) Everted feet; though 
the arches have not fallen they are often 
exaggerated. (5) Turning in of the toes, 
the child walking on the outer side of the 
foot. All these clinical phases result from 
a varying degree of loss of the angle of 
dorsi-flexiou of the foot, due to contraction 
of the calf muscles and tendo-Achillis. This 
produces shortening of the stride in walk- 
ing, the patient being in uncertain equili- 
brium if he attempts to take a long step. 
If allowed to proceed, the condition deve- 
lops into ordinary talipes, and recognition 
and appropriate treatment of these slighter 
degrees of contraction are essential. In 
examining the child, the movement of 
dorsi-flexiou of the foot should be slow* 
gentle, and steady, and one examination is 
often insufficient to determine the degree of 


contraction present. The condition is usu- case was aspirated and injected twice with- 

ally due to infantile paralysis, and the in a short period. No attempt is made to 

difficulty in walking and other symptoms explain whether the effect is from the 

described to the surgeon frequently begin hyperemia, or by the chemical effect on the 

with one of the exanthemata. Another set bacteria. The abdomen is tapped with a 

of causes is associated with throat lesions, trocar and canula, about 1000 to 1500 c.c. 

and in Anglo-Indian children there is often of fluid removed, and then the same 

a history of one or two attacks of "fever." amount of oxygen is injected, under two to 

The treatment presents considerable diffi- three atmospheres of pressure. The oxy- 

culty. If, with the limb fully extended, gen is made fresh from potassium chloride 

the foot is incapable of dorsi-flexion beyond and potassium permanganate, 
a right angle, it is advisable to lengthen 

the tendo-Achillis. An open operation is IntraparletBl Hernia with Very Small Per- 
i i ,i . j i • , ,i j Itoneal Opening, Giving Rise to Severe 

recommended, the ten do being lengthened M Abdominal Pain. 

by the Z-shaped method. A transverse AT , s 

incision is made halfway through the ten- Macewan_(Lancet) reports the case of a 
don, the knife carried vertically downwards woman of 5/ years who had had for 27 
for a distance of one to one-half inch, then >' ears abdominal pain about midway be- 
turned on the flat, the remaining part of tween the navel and symphysis, about two 
the tendon cut through transversely, and inches to the right of the median hue. A 
the two portions slid upon one another un- sma11 umbilical hernia was found and later 
til the desired degree of lengthening is ob- a mass the size of the closed fist with a 
tained. In cases where there is only a narrow pedicle, extending toward the ab- 
small diminution of five degrees or so of domen. On lying down, this .mass disap- 
the angle of dorsi-flexion, passive and ac- Pfared with a sudden slip and a slight gur- 
tive movements designed to stretch the & le : ^ he umbilical hernia was first treated 
contracted structures are advisable, and and then the inner surface of the abdominal 
much assistance is afforded by a boot with wal1 was inspected. At the point above 
a toe-uplifting spring. If these measures nam ^ d as Pamful, inspection revealed a 
fail, recourse may be had to the method of sma11 raised area with a minute central de- 
operation described. pression. So small was this depression 

that it was doubtful if it would admit a 
Intraperitoneal Injection of Oxygen for probe. Slight pressure with the point of 
Tuberculous Ascites:— Schulze (Mit. a. d. the probe, however, served to gain access 
Grenz. d Med. u. Chir.,) gives a compari- to what appeared to be a small sac in the 
son of the various forms of treatment for abdominal wall. Dressing forceps were 
tuberculosis of the peritoneum, and the next tried and it was found that the minute 
theories which account for the cures after mouth of the sac was extremely distensible, 
exploratory laparotomies. He then pre- easily opening sufficiently to admit the 
seuts the method of Moyer and Schmidt, of finger, which penetrated a distance of one 
injecting oxygen after the aspiration of and a half inches when a little pressure 
tuberculous ascites. Reasoning from the was applied. An incision was now made 
fact that a fairly large proportion of the round the mouth of the sac in the normal 
operated cases recover, and remain free peritoneum and the sac, which then lay 
from ascites, and knowing that simple as- loosely in the abdominal wall, was dissect- 
piratiou of fluid is rapidly followed by its edout. While very small when relaxed, 
return, they decided to combine the subse- and, as already stated, possessing a very 
quent injection of oxygen after aspiration narrow mouth, it was capable of great dis- 
to imitate the entrance of air during opera- tention, extending easily to the size of a 
tion. The report is based on six cases so tangerine orange. A futher point of in- 
treated over a year and a half ago. All re- terest was that the omentum, instead of ly- 
main alive and are able to work. Five re- ing in front of the coils of bowel, had be- 
ceived only one puncture and oxygen in- com e turned up, its free border being at- 
jection, one case receiving two, the latter tached to the stomach and the whole being 
having had a laparotomy previous to the lade u with fat. An attempt was made to 
first injection. In one case the tumor remedy this and a redundant portion was 
masses entirely disappeared, and in another removed. The wounds were now sutured, 
they ceased to give trouble. In all the particular care being taken to secure ac- 
cases the injection was supposed to do curate apposition of the cut peritoneal sur- 

good; in half of the cases there was a reac 
tion immediately following, such as pain 
or vomiting, the fluid slightly increased, 

faces, and the patient was returned to bed. 
She made an uninterrupted recovery and 

but later the ascites was entirely absorbed, has had no further trouble, the pain having 
Late recurrences were not met, but one quite disappeared. 


On the Use of Massage and Movement In 
the Treatment of Fractures. 

Cathcart (Glasgow Med. Jour.) directs 
attention to the massage and movement 
method of treating feactures, and shows 
how almost every fracture in the body can 
have this method applied to it with much 
benefit t<> the patient. He arrives at the 
following conclusions after a study of the 
literature and reviewing his personal ex- 
perience: Absolute immobility of the 
broken ends of bone is not essential to bony 
union. The ribs unite in spite of the move- 
ments of respiration, and wide experience 
has shown that the slight amount of move- 
ment, necessarily involved in the daily 
massage of a fractured limb, and in the 
daily active and passive movements for a 
few minutes, at least, of the adjacent joints, 
seems to hasten rather than hinder the for- 
mation and the solidification of the callus. 
Extravasated blood in joints and among 
muscles and synovial sheaths leads to ad- 
hesions in its neighborhood, as if it were in 
itself a source of irritation, apart from the 
irritation due to bruising and laceration of 
these soft parts which accompanies frac- 
ture. Massage in the form of stroking and 
gentle kneading and with it occasional 
movements, are in several ways beneficial 
in the treatment of fracture. These meas- 
ures not only aid the actual union of the 
bones, but help in the absorption of ef- 
fused blood and serum, restrain if not pre- 
vent the formation of adhesions among the 
soft parts, and maintain the nutrition of the 
muscles. They, therefore, simultaneously 
hasten union and prepare the limb to return 
to functional use, almost as soon as the 
bones are united. Splints and other reten- 
tive apparatus, including extension, are 
required more to prevent mal-uniou than 
non-union, and hence are called for, especi- 
ally where the weight of the limb or mus- 
cular action are likely to lead to bad posi- 
tion during the healing. Anyone suffici- 
ently careful and gentle in handling an in- 
jured and delicate part can do this massage 
and manipulation, the objects of which are 
in recent fracture to diminish the swelling, 
allay muscular spasm and soothe pain, in 
later stages to stimulate circulation, dis- 
perse accumulations of blood and serum 
and maintain nutrition of muscles, nerves 
and soft parts. The patient must be caused 
pain. The author then gives directions for 
thetreatmenl of special fractures and calls 
attention to the fact that splints and exten- 
sion must be employed meanwhile to sup- 
ply the rest and fixation necessary. In 
certain fractures, as that of the clavicle, 
none of the appliances so For used prevent 
a certain amount of overriding; a good 
functional result is here obtained by the 

use of a simple sling with the arm firmly 
supported at the side. Simplification of 
apparatus is a desirable thing, and the 
writer is of the opinion that much can be 
accomplished in this direction. 

The Intracellular Occurrence of Tubercle 
Bacilli In the Sputum. 

Lowenstein (Deutsche Mediziuische 
Wochenschrift, ) says that among the fac- 
tors that have to be considered in opsonic 
work is the individual susceptibility of dif- 
ferent strains of bacilli to phagocytosis. 
For example, all strains of tubercle bacilli 
do not behave in the same way in regard to 
the phagocytes, some being readily engul- 
fed by these, while others exhibit great re- 
sistance to the process. The conditions in 
the living body and in vitro are also very 
different, as is shown by a case of tuber- 
culosis of the bladder in which the pus cells 
never contained tubercle bacilli, although 
these were present in great numbers be- 
tween the leucocytes. If some of the pa- 
tient's own serum and tubercle bacilli were 
added to the urinary sediment, active phago- 
cytosis took place in a short time. It is 
therefore possible in vitro to secure phago- 
cytosis by the aid of the same factors that 
in the body itself are ineffectual. The 
author further discusses the occurrence of 
phagocytosis in tuberculous sputum. He 
has found that the leucocytes of the sputum 
of tuberculous patients contain the bacilli 
in chronic cases of very long duration and 
in recent cases in which the prognosis is 
favorable. The phenomenon is also ob- 
served in instances in which specific treat- 
ment with tuberculin or bacterial emulsions 
has been carried out. Until the conditions 
underlying phagocytosis in the body itself 
have been more thoroughly investigated, 
the author believes that the application of 
the determinations of the opsonic index will 
not be fruitful in practice. 

Acetonaemia in Children:— j a n „•_ 

mead (Brit. Med. Journal, ) groups the pa- 
tients whose urine shows diacetic acid and 
acetone, as follows: 1. Those usually 
showing no symptoms of acidosis. Among 
these are cases of excessive fat ingestion, 
starvation, high fevers, gastric ulcer, malig- 
nant disease, all due to deprivation of car- 
bohydrates. 2. Those who, while having 
other diseases, have also symptoms of acid 
poisoning, but masked by the primary con- 
dition. Such are patients with diabetes, 
intracranial disease, and certain poisons, 
such as morphine, phloridzin, and sodium 
salicylate. 3. Those who suffer from un- 
complicated acidosis which per se may end 
fatally. These are the subjects of delayed 
anaesthetic poisoning, and recurrent, cycli- 



cal, or periodic vomiting conditions which 
may be designated by the term "cryptogenic 
acidosis." The symptoms of acidosis are 
dulness and apathy, increasing to drowsi- 
ness and coma; the face is flushed, the eyes 
are bright, and there is great thirst. An 
odor of acetone may be detected on the 
breath. The urine contains acetone, dia- 
cetic acid, and sometimes beta oxybutyric 
acid. There is extremely rapid wasting, 
and hyperpyrexia may occur at the end. 
The writer sums up his conclusions as fol- 
lows: 1. Acetone and diacetic acid are 
found in the urine in a number of condi- 
tions, and may be, but are not necessarily 
associated with symptoms of acidosis. 2. 
Delayed anaesthetic poisoning and cyclical 
vomiting are instances of acidosis of un- 
known origin. 3. Anaesthetic poisoning is 
due to the state of anaesthesia more than to 
the particular anaesthetic. 4. The acetone 
series is a product of the imperfect oxida- 
tion of fats, so that in these conditions the 
oxidizing powers of the tissues must be in- 
adequate. 5. This is further shown by 
the condition of the liver. 6. The failure 
of oxidation is probably due to too great a 
supply of fat rather than to a deficiency in 
oxidizing power. 7. This is probably 
brought about by toxines acting like phos- 
phorus. 8. The determining cause of aci- 
dosis is the accumulation of the precursors 
of acetone. 9. Anaesthetics are dangerous 
to patients who are the subjects of acidosis. 

The Aetiological Diagnosis of Typhoid 

Fever:-R au bitschek (Wiener Klin. Wch- 
schrft.) describes a special procedure for 
the purpose of demonstrating typhoid bac- 
illi in the urine. The majority of the typ- 
hoid bacilli present in the urine may be 
obtained in this manner for culture. In 
those cases where the agents of typhoid 
fever are only scantily excreted in the urine 
there are better prospects for their culture 
than by direct admixture of typhoid urine 
and agar-agar. The excretion of typhoid 
bacilli through the urine is in no way de- 
pendent upon the stage of the disease or the 
severity of the case. It occurs not only 
during convalescence, but already about 
the time of the eruption of the rose spots, 
or even a short time previously. 

The demonstration of typhoid bacilli by 
cultures from the blood represents an im- 
portant guide to early diagnosis, which is 
doubly valuable because the positive de- 
monstration of the aetiological factor abso- 
lutely proves the existence of the disease. 
The interference in shape of venous punc- 
ture is practically devoid of danger, not at 
all difficult from the technical point of view, 
very nearly painless and less objectionable 
to the majority of patients than the with- 

drawal of a few drops of blood from the 
lobe of the ear. With special reference to 
complications, the author observed the oc- 
currence of a haematoma having about the 
size of a bean in two cases only. 

Acule Miliary Tuberculosis Following 
Intubation ol Larynx:- Pr i mavera (Gior. 
Internez. delle Sci. Med.,) states that acute 
military tuberculosis may follow the trau- 
matism due to intubation and extubation 
for laryngeal stenosis in cases in which 
there was a local tubercular focus in the 
larynx before the complication that caused 
the stenosis. He cites two cases of stenosis 
due to diphtheria, followed by acute mili- 
tary tuberculosis, in which the frequent in- 
troduction and removal of the tube necessi- 
tated by the difficulty of breathing without 
the tube had caused breaking down of the 
tissues to a marked degree. Traumatism is 
a cause of generalization of bacilli from a lo- 
cal focus. The inflammatory reaction of 
the traumatism sets in movement the bacilli 
or breaks the capsule of fibrous material 
which has inclosed the old focus. Acute 
miliary tuberculosis is not a primary pro- 
cess, originating from without; but an endo- 
genous origin is necessary to prepare the 
enormous number of bacilli that are neces- 
sary to originate the numerous tubercles in 
all parts of the body. The bacillus does 
not multiply rapidly enough to produce 
them from a new focus. Hence we must 
always presuppose an old focus that has ap- 
parently healed. Tubercular vessels are a 
very frequent source of such infection. Sur- 
gical operations or procedures are a frequ- 
ent starting point for such dissemination. 
In each of the children there was found at 
the autopsy a laryngeal condition that would 
indicate an advanced stage of tubercular 
degeneratisn, which must have existed for 
some time before the advent of the diph- 
theritic process that necessitated intubatiou. 
The course of the disease was short after 
the intubation han been done, the little pa- 
tients dying in a few weeks of acute miliary 

Nasopharynx as Infection Carrier In Cere- 
brospinal Meningitis. 

Fraser and Comrie (Scot. Med. and Surg. 
Jour.,) have examined the nasopharynx in 
thirteen cases of the disease, and in sixty- 
nine persons coming into immediate contact 
with them. While the organism was found 
in ^^ per cent, of the fathers of cases, among 
other equally close contacts it was discov- 
ered only in 9 per cent. The writers failed 
to find the meningococcus in the nasophar- 
ynx of twenty-three contacts. They believe 
that hot, dusty, ill-ventilated atmospheres, 
which provide conditions favorable to the 



growth of the meningococcus and to the oc- 
currence of nasopharyngeal catarrh, are 
often associated with the dissemination of 
epidemic cerebrospinal meningitis. The 

high comparative percentage of fathers, 
whose nasopharynx was found to contain 
the meningococcus, points to the fact that 
they probably are the carriers of the disease 
to their children. The chief incidence of 
the disease in the Leith epidemic was among 
children of the lower clases, and this is in 
favor of a nasopharyngeal infection. Infec- 
tion of the nasopharynx is undoubtedly an 
important factor in spreading the disease. It 
is advisable to isolate all contacts and to 
carry out a bacteriological examination of 
the nose and nasopharynx. If the men- 
ingococcus be present these cavities should 
be disinfected, and the contacts should only 
be allowed to leave quarantine after the 
nasopharynx has been reported free from 
the meningococcus on two consecutive oc- 

The Practical Application of the Demon- 
stration of the Splrochaeta Pallida. 

Arningand Klein, (Deutsche medizinis* 
che YVochenschrift, ) in reporting the results 
of their work in the examination of the pa- 
tients in the Hamburg St. George Hospital 
for veneral diseases, say that they have 
reached the conviction that the Spirochseta 
pallida is the cause of syphilis and is path- 
ognomonic for the disease when discovered 
in suspected lesions. The search for this 
organism should be made a routine in hos- 
pital work and in time will also be necessary 
in the work of the practising physician. 
The staining method that proved most satis- 
factory in the hands of the authors was the 
I'reiss modification of the Giemsa stain. 
( )ne hundred and forty cases of clinical 
chancres were examined, 1 12 of these being 
on the male genitals. In only four instances 
were the spirochetes not found, the reason 
in two of the cases being that the ulcers had 
already undergone prolonged local treat- 
ment with mercury. In fourteen primary 
lesions of the female genitals the spirochetes 
were discovered in every instanc. Only ten 
failures are reported in 17') cases of syphili- 
tic plaques and patches of various sorts. 
en cas.-s of suspected or actual con- 
genital syphilis were examined and in every 
instance in which clinical syphilis existed 
the spirochetes were found. In thirty-two 
cases in which the diagnosis was clinically 
uncertain the spirochetes were found seven 
times and the subsequent clinical course 
was that of syphilis. Eighteen cases gave 
a negative resull and were treated as soft 
chancres, but in two of these the occurrence 
of secondary symptoms showed that the 
search for spirochetes had not been suffici- 

ently prolonged. In the remaining seven 
cases treatment by mercury had already 
been administered and no spirochetes w T ere 
found. In ninety-three cases the clinical 
picture was that of soft chancre and the ex- 
amination was made as a species of control; 
in two of these the spirochete was found, 
but the others, in w T hich a very careful search 
failed to detect the microorganism, ran the 
clinical course of nonsyphilitic affections. 

The Operative Treatment of Inguinal Her- 
nia In Chlldron. 

Buhlmann (Deutsch. Zeitschrift f . Chir.,) 
says the treatment of hernia in early infancy 
by means of trusses does not afford the re- 
liable prospects of a radical cure, which is 
obtainable only by operative treatment. The 
results of surgical interference are excellent, 
as shown by Tavel's material, quoted by 
the author. In the three years from 1902- 
1905 117 children were operated upon, with 
a total of 144 operations. The cases were 
re-examined at the end of six months. There 
was only one recurrence, in the case of a 
premature child with a large umbilical her- 
nia, which contained the stomach and the 
liver. Atrophy of the testicles did not oc- 
cur in a single instance. The course was 
entirely free from reaction in all but five 
cases; a relapse failed to occur in these 
cases also. 

From the technical point of view the 
facility of the operation increases with the 
timeliness of its performance on account of 
the absence of adhesions. The principal 
steps of the procedure are as follows: An 
incision is made parallel to Poupart's liga- 
ment above the neck of the hernial sac; 
next, incision of the tunica communis in 
the longitudinal direction; detachment of 
the constituents of the spermatic cord from 
the hernial sac; then the sac is pulled out 
and detached from the inguinal canal under 
preservation of the lateral vesico-umbilical 
ligation and oblation of the sac, the stump 
slipping back into the abdominal cavity; 
suture in layers, and gauze dressings with 
iodoform or iodo-galliciu. 

With special reference to the eetiology of 
inguinal hernia, the condition depends up- 
on the more or less atypical or incomplete 
obliteration of the processus vaginalis. The 
patency of this process creates an immedi- 
ate predisposition to the development of in- 
guinal hernia. A contributing causative 
factor consists in the remarkably strong ab- 
dominal pressure action as it exists in in- 
fancy. It is a result of anatomical condi- 
tions that young infants almost exclusively 
present oblique inguinal hernia is absent, in 
contradistinction to the adult cases. In his 
studies upon the cadaver the author obser- 
ved the new fact that the inguinal canal in 



the new-born follows a course almost par- 
allel to that of the median line of the body. 
In the adult, with an oblique course of the 
canal, the abdominal pressure action results 
rather in a compression of the canal. Direct 
hernia in infants is prevented by the ap- 
proximation of the vesico-umbilical and 
epigastric folds. 

The Microbe of Whooplnft-Gough. 

Bordet and Gengon (Ann. del'Inst. Pas- 
ture, ) says the first expectorations in per- 
tussis, coming from deeply within the bron- 
chial trunk, are found to contain a very 
small oval micro-organism in almost a pure 
culture. This microbe takes the stain of 
Kuhne's phenylmethylene-blue, but not the 
Gram stain. It may be grown upon a mix- 
ture of defibrinated blood with gelatine and 
glycerine and a decoction of potato, or up- 
on gelatine and ascites fluid. At a later 
stage other germs become associated with 
it, so that the bacillus of pertussis is not so 
readily obtained. The authors conclude 
from their agglutination experiments that 
this microbe is the agent of pertussis, since 
only the serum of children having whoop- 
ing-cough has an agglutinating effect, 
which is absent in other serum. 

Differential Diagnosis Between Renal Dis- 
ease and Perityphlitis. 

Schlesinger(Deutsch. Med. Wocheuschr) 
mentions several instructive findings that 
resulted from the observation of a number 
of cases in Israel's clinic. Red blood cor- 
puscles may appear in the urine of perity- 
phlitis and may be absent in nephrolithia- 
sis when there is an incarcerated ureteral 
calculus. Pain radiating into buttocks, 
hips and legs is due to an extra-peritoneal 
lesion and therefore suggests a renal origin. 
But the appendix, too, may be extra-peri- 
toneal and may then produce the same 
phenomenon. Violent pain radiating into 
testicles and penis speaks for disease of the 
urinary tract, but bladder disturbances were 
found sometimes to be due to perityphlitis. 
Finally, cases of renal colic were observed 
closely simulating ileus. 

Pathogeny of Phlegmasia Alba Dolens. 

Keim (LaPresse Medicale, ) believes that 
there are cases of phlegmasia alba dolens 
that are not the result of infections from 
without. It may follow a perfectly normal 
puerperal state, and is rare in serious infec- 
tions as well as in abortions, which are fre- 
quently accompanied by infection. After 
delivery coagulation may result from an 
abnormal blood condition due to imperfect 
function of the liver. During pregnancy 
these functions are altered and the blood 
becomes more coagulable than normal. 

There is an excess of fibrin. Injections of 
plain water or sublimate render coagulation 
easier. The treatment of this condition 
should aim to stimulate contraction and in- 
crease the anticoagulating function of the 
liver. Intrauterine douches should not be 
given, and all clots and placental remains 
should be removed. At the end of pregn- 
ancy intestinal affections aid in producing 
toxemia. There are internal coagulations 
in the abdominal veins from pressure, which 
after the traumatism of labor are propagat- 
ed to the veins of the leg. Intestinal toxins 
act upon the liver again and lessen coagu- 
lating power. Practical deductions are 
that intestinal conditions should be care- 
fully watched during pregnancy, constipa- 
tion and enteritis treated at once, and in- 
testinal lavage made with alkaline solutions 
and peroxide of hydrogen. The venous 
system is at the same time treated by giving 
liamamelis virginica and strychnine. After 
delivery the uterus should be carefully emp- 
tied and contraction hastened by hot vagi- 
nal douches and ergot. 

Mobile Kidney, with a Description of an 
Operation for Anterior Nephropexy. 

Bishop (The Lancet) says that the cases 
in which practical men are interested fall 
into the category of "mobile" or "wander- 
ing" kidney, are not surrounded by peri- 
toneum, and their excursions take place 
entirely behind the parietal peritoneum in 
the loosened subperitoneal connective tissue 
Regarding this variety there are only four 
points on which writers appear to be agreed, 
viz., that such a condition actually exists, 
that it is most frequent in women, that it is 
most frequently seen on the right side, and 
that it is very frequently associated with 
neurasthenia. After quite an exhaustive 
review of the literature, he describes his 
operation as follows: An obliquely trans- 
verse incision is made through the muscles 
of the abdominal wall outside the rectus 
muscle. This gives free access to the renal 
fossa on the right side. The liver being 
lifted, the stomach drawn inwards, and the 
hepatic flexure of the colon depressed by 
broad retractors or large flat sponges, the 
parietal peritoneum is divided transversely 
over the lower fourth of the kidney. The 
two peritoneal edges being held apart, a 
curved incision, concave upwards and out- 
wards, is made in the proper capsule, and 
the lower segment of this loosened from the 
anterior renal surface down to its inner and 
lower extremity. This capsule remains at- 
tached to the posterior surface of the organ. 
Its flap is turned downwards and inwards, 
leaving the raw surface of the kidney ex- 
posed for a corresponding distance. Two 
or three sutures attach this loosened edge 



of the capsule to the fascia beneath. The 
peritoneum is sewn up by catgut. The an- 
terior surface of the lower leaflet of the true 
capsule is now in contact with the posterior 
abdominal wall, and the posterior surface 
of the peritoneum is lying upon it and upon 
the bared lower anterior renal tissue. A 
long straight needle, armed with iodized or 
chromicized catgut. No. 3, is pushed direct- 
ly backwards immediately below the uret- 
eral insertion until its point emerges be- 
hind; another needle carries the opposite 
end of the same thread, and is pushed 
through one centimeter below the first. 
When both needles are drawn through the 
thread is tied over the muscular layer be- 
hind the peritoneum, capsule, and posterier 
tissues are united on the inner side of the 
lower pole of the kidney. Another pair of 
needles is placed in a similar manner so as 
to carry a loop of catgut below the inner 
lower angle. Two or three more carry loops 
below the kidney. All these pass through 
peritoneum, capsule, subperitoneal connec- 
tive tissue and muscles. When drawn tight 
and tied the kidney will be supported by a 
row of sutures which do not penetrate its 
substance, but which effectually fix it. The 
closure of the abdominal wall in tier fash- 
ion completes the operation. 


Hacker (C.yn. Rund.) discusses the re- 
lations of pubiotomy and symphyseotomy 
and their advantages. The strongest argu- 
ment against symphyseotomy has been that 
a wound of a joint is more difficult to heal 
than that of a bone; but the symphysis is 
not a true joint and possesses no synovial 
membrane. If it is more open to infection 
the answer is perfect asepsis. The symphy- 
seotomy wound cannot be well protected 
against infection if we await a spontaneous 
delivery after the operation, The mortality 
of pubiotomv and symphyseotomy is not 
less than that of Cesarean section and in- 
jury of the soft parts is liable to follow 
either of these operations. The most fre- 
quent is injury of the corpus cavernosum, 
of the clitoris, or the pudendal artery, either 
of which will produce hemorrhage. With 
the subcutaneous method this is still more 
liable to occur. The bladder and vagina 
may be injured, especially when previous 
inflammatory processes have caused adhes- 
ions of the bladder to the symphysis. The 
liability to injury of the bladder when in its 
natural position is greater in symphyseoto- 
my, hut the pubiotomy needle may also 
puncture it when used subcutaneously. In 
third degree contractions the delivery of the 
child may cause tearing of the bladder 
through the force necessary to delivery. The 
dangers seem to be equal in these two oper- 

ations, but by improvement of technique 
they may be lessened in pubiotomy. Ad- 
vocates claim greater widening of the pelvic 
diameters in symphyseotomy. The author 
finds that the increased width if equal in 
the two operations. Severe degrees of con- 
traction are not suitable for either of these 
operations, but should be left to Cesarean 
section. The pelvic outlet is not much in- 
creased in width on account of the pelvic 
diaphragm which resists the spreading of 
the bones. The oblique diameter is in- 
creased more than the antero-posterior 
diameter. The widening seems to be about 
the same in the two operations, and the 
limits are the same, only the second grade 
of contraction being suitable for them. The 
union is generally fibrous in both cases, a 
bony union being rare, and fibrous union 
allows of a little more room by stretching 
of the point of union during the next de- 
livery. The author believes that these two 
operations stand on the same plane and are 
equally indicated. But the mortality has 
not been much reduced by the use of these 
operations. It is 5 to 6 per cent, for the 
mother. The soft-part injuries and the 
formation of hematomata are distinct disad- 
vantages of them and infection may occur. 
Hemorrhage is generally slight, but hema- 
tomata constitute a distinct danger. Most 
of the soft-part injuries may be avoided by 
care in delivery. The author believes that 
only the original form of pubiotomy is justi- 
fiable, and that the subcutaneous form 
should be discarded. At the present day 
the tendency is to await a spontaneous de- 
livery after operation, rather than to deliver 
by forceps or version . 

Tuberculous Diseases of the Oesopha- 
gus and the Stomach:— The author contri- 
butes a compilation of all the published 
cases, to which is added a personal obser- 
vation on a case of tuberculous ulceration 
in the stomach and the oesophagus, with 
autopsy findings. To his study of the post- 
mortem material of the Kronstadt Navy 
Hospital, including 18,593 autopsies be- 
tween the years 1871-1905, he found 25 
cases of probably tuberculous gastric ulcer 
and 5 cases of oesophageal ulceration. The 
origin of the disease is usually referrable to 
direct inoculation; more rarely the infection 
travels by way of the blood. The disease, 
which is secondary in the majority of cases, 
does not, as a rule, give rise to very distinct 
symptoms. In those cases where the affec- 
tion takes the course of gastric ulcer or 
pyloric stenosis it can sometimes be recog- 
nized by the diminished acidity of the gast- 
ric juice. In exceptional cases and in 
robust patients surgical treatment may en- 
ter into consideration in the presence of 



pyloric stenosis or gastric ulcer. — Russki 
Vratsch . 

Diagnosis of Epidemic Cerebrospinal 
Meningitis In Infants:— Progulski says that 
no other infectious disease of childhood pre- 
sents the same variability of symptoms as 
epidemic cerebrospinal meningitis, and the 
disease is therefore frequently misinterpret- 
ed in the rapid examinations of ambulant 
clinical material. In the majority of the 
cases the disease begins suddenly in previ- 
ously healthy infants. Less commonly 
there has been general- malaise for a short 
time before the onset of the disease. Vomit- 
ing, although common in older children and 
in adults, is very rare in infants, as is also 
rigidity at the nape of the neck. One of 
the most important signs, which is promi- 
nent in all there infants, is a rise of tem- 
perature, the curve of the fever showing a 
similar course as in all suppurative diseases; 
also great restlessnesc and excitement under 
preservation of consciousness. Convulsions 
are a less typical sign, and Kernig's symp- 
tom is equally rare. Certain cases are 
characterized by an eruption of the skin, 
which persists for a short time only, never 
extending to the mucous membranes. The 
presence of a similar cutaneous eruption, 
together with general malaise, is suggestive 
of cerebrospinal meningitis. According to 
the author a very important symptom in 
young infants consists in an exaggerated 
appetite, together with progressive emacia- 
tion. Older children, on the other hand, 
are affected with anorexia; often with a 
clean tongue and no gastric derangement. 
— Livowski tygodnik lekarski; Centralblt. 
f. inn. Med. 

A Case of Xeroderma Pigmentosum 
Without Pigmentation: -Audry reports a 
case in whom since childhood the following 
symptoms of xeroderma pigmentosum were 
exhibited: The skin was dry and diffusely 
atrophic and erythematous, and there were 
achromatic spots and telangiectases. There 
was a lack, however, of pigmentation, with 
the exception of a few ephelides upon the 
back of the hands. The writer repeats his 
former conception of this malady, namely, 
that it is a congenital dyskeratosis, the 
main symptom being represented by the 
erythematous, pseudo-icthyotic atrophy of 
the skin. The other symptoms are consi- 
dered of secondary importance. The writer 
does not recognize a xeroderma pigmento- 
sum tardivum. — Annal. dedermatol. et. de. 

Further Investigation With the Microspo- 

Ill continuing his experiments with the 

microsporon Sabouraud has recently dis- 
covered three new varieties of this fungus. 
Hitherto, in addition to the Microsporon 
Audouini, microspora occurring in the 
horse, dog and cat had been recognized. Of 
the three new varieties, two are encountered 
rarely and are distinguished only by cul- 
ture. They cannot be distinguished clini- 
cally or histologically. The third variety, 
which the author calls Microsporon lauo- 
sum, was found in about a third of the cases 
of herpes tonsurans that were examined. It 
produces such a typical picture that its pres- 
ence can generally be recognized clinically. 
Cultures of this variety grow very readily 
and resemble in this respect the microspora 
of the cat and dog. As it is futher easily 
inoculable in animals, it seems likely that 
it is of animal rather than human origin. 
This has not as yet, however, been proven. 
Upon the human scalp the microsporon 
lanosum produces small patches, covered 
with gray scales, and which show very few 
normal hairs. The appearance of the hairs 
is that seen in every variety of trichophyto- 
sis. The patches after a few days frequent- 
ly assume an inflammatory aspect. There 
is a noticeable tendency for the patches to 
spread upon the surrounding healthy scalp. 
A herpes irislike picture can then result. — 
Annal. de dermatol. et de syph. 

The Treatment of Typhoid Bacilli Carrier* 

Dehler (Munchener medizinische Woch- 
enschrift, ) says that he believes that in cases 
in which typhoid bacilli are habitually cast 
off in the feces, but are not present in the 
blood or urine, operative cleansing of the 
gall-bladder is indicated. He describes two 
cases in which the patients, two inmates of 
an institution for the insane, were apparent- 
ly freed from the typhoid bacilli by drain- 
age of the gall-bladder. In the first case 
before the operation 37 out of 39 examina- 
tions of the stools were positive for typhoid 
bacilli, whereas of 176 examinations made 
after the operation the organisms were 
found in only 3. In the second patient, 
who apparently had never suffered from typ- 
hoid fever, before the operation 30 out of 55 
examinations of the stools were positive; 
after the operation 28 out of 30 examina- 
tions were negative. In both cases the ad- 
ministration of intestinal antiseptics had 
been ineffectual in removing the organisms 
from the feces. 

The Treatment of Malignant Growths With 
Organic Extracts. 

Bergers and Stickers (Deutsche medin- 
sche Wochenschrift) speakr of the results 
that have already been obtained in cases of 
experimental new growths by injecting sub- 
stances extracted from normal livers. In 


this way it has been possible to produce ne- 
crosis and liquefaction of carcinomas and 
sarcomas, and the theory has been suggest- 
ed that the unrestrained growth of malign- 
ant neoplasms is due to the absence or in- 
sufficient quantity of similar ferment-like 
bodies. These results have not as yet been 
susceptible of clinical application, however, 
since it has so far not been found possible 
to produce the local effect without also giv- 
ing rise to toxic symptoms. In experi- 
ments on mice it was also found impossible 
to cause complete disintegration of the tu- 
mor without endangering the life of the an- 
imal through the toxic action of the organ 
extracts. In the present communication 
the authors describe a similar effect which 
was produced on advanced experimental 
sarcoma of the dog. The injection of the 
specific liver ferments caused regressive 
changes in the growth leading to its com- 
plete disappearance after it had already 
reached a stage of development that exclu- 
ded the possibility of spontaneous cure. In 
this instance also the authors warn against 
a too sanguine attitude in regard to the ap- 
plication of the method to similar conditions 
of man, though they consider that the re- 
sults obtained will be found of great theo- 
retical value. 

Action of Morphine Upon the Genital Ap- 
paratus of ths Woman. 

Lutauda (Journal de Medicine de Paris) 
has found, in the course of several years of 
treatment of drug habitues that the effect of 
the morphine habit on women is to stop 
menstruation and to take away all sexual 
desire. Others give the same experiences 
with men. The author thinks that we may 
make use of these facts in the treatment of 
gynecological diseases in which there is 
metrorrhagia with benefit to the patient. 
Such conditions as menorrhagia without 
lesions, menorrhagia and metrorrhagia due 
to fibromata, and that due to the destruc- 
tion of the tissue by cancer. In the first 
class of cases there are whose profuse men- 
struation menaces life and here morphine 
may save life, and yet the patient may not 
become a morphine habitue if the drug is 
withdrawn skillfully. In fibromata its use 
may serve to tide over a few years until the 
menopause changes put an end to the 
growth of the fibroid and atrophy takes 
place [n cases of uterine cancer it is the 
duty of the physician to makeof his patient 
a morphine taker, since only thus can she 
be comfortable for the rest of her existence. 
The author has seen cases in which the use 
of morphine has nol only made the patient 
comfortable for years, but has actually pro- 
longed life. It retards vita! exchanges, 
lessens secretions, and retards the evolution 
of the neoplasm, and life is longer. 

The Thymus and Death In the Course of 
General Anaethesla. 

Lapoute (Le Progres Medical) ranks 
among the conditions that render anaesthe- 
sia dangerous abnormal persistence of the 
thymus gland after birth. It is associated 
with hypertrophy of the lymphatic organs 
and the lymphadeuoid tissues. The author 
has found in literature 33 examples of sud- 
den death under general anaesthesia in such 
persons, and to them adds two observed by 
himself. The dominant symptom is the 
presence of a large thymus. The evolution 
of this gland consists of a period of growth 
followed by one of regression, ending nor- 
mally in the second year of life, abnormally 
from the fifth to the twenty-fifth year. 
There are vestiges of the gland even in the 
most advanced age. Histologic changes 
go on that are curious; at first they are eph- 
ithelial, later fatty changes go on. Persist- 
ent thymus is only one feature of the status 
lymphaticus. There is almost always en- 
largement of the lymphatic glands, and ex- 
uberent adenoid tissue in the pharynx, and 
in the Peyer's patches of the intestine. 
Sometimes the thyroid gland is also hyper- 
plastic, and there is corpulence combined 
with the other changes. The form of an- 
aesthetic used seems to have no effect on 
the occurrence of sudden deaths in such 
subjects. The respiration becomes slowed, 
and the pulse imperceptible; then the heart 
stops and the pupils dilate rapidly. Arti- 
ficial respiration will cause a few breaths 
after the stoppage of the heart. The theory 
of the compression of the trachea and great 
vessels by the thymus is hardly tenable as 
a cause of death. Xo compression has been 
found at the autopsy in any case. Hyper- 
thymization, that is that the thymus throws 
into the circulation toxic substances that 
create a pathological excitation of the car- 
diac nervous centres, which react reflexly, 
is also proposed. On this supposition it is 
advisable to lessen all nervous excitations 
bef°re the operation by the use of drugs. 
In everv case in which there are evidences 
of the status lymphaticus, scopolainine- 
morphine solution should be injected so as 
to produce a calm sleep, and then anaes- 
thesia should be begun during the sleep. 

I The Suprarenal Glands. 

Kollestou (Lancet) discusses certain 
problems connected with the secretion and 
functions of the various portions of the su- 
prarenal glands. Three views have been 
put forward as to the function of the cortex: 
1 1 ) That it is connected with growth, es- 
pecially of the sexual organs; I 2 ) that it is 
antitoxic: ( 3 ) that it plays some part in the 
elaboration of the internal secretions of the 
medulla. A priori it would seem improb- 






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able that the cortex discharges all three 
functions, but it is suggested that each of 
the three /ones of the cortex — zona glouie- 
Fulosa, zona fasciculata, and zona reticula- 
ris— performs a different function. The co- 
relation of the cortex with sexual growth, is 
the most definite thing known. As regards 
the medulla, complete absence of its inter- 
nal secretion is met with in Addison's dis- 
eade. This is proved by the inactive con- 
dition of such suprarenal glands when test- 
en physiologically. The suprarenal medul- 
la map also be devoid of adrelin in patients 
dying from chronic exhausting diseases. It 
is possible that intestinal toxins may also 
act on the cells of the adrenal medulla as 
to produce an internal secretion of such an 
abnormal character that the normal process 
of transformation of any excess into an in- 
active body cannot be carried out by the 
tissues. The excess of such an abnormal 
adrenalin might conceivably cause high ar- 
terial pressure, arterio-sclerosis, and the al- 
lied morbid changes. 

The Origin of Seasickness. 

Lund (The Practitioner,) concludes a 
studyjof this affection with the statement 
that there is some mechanism in the audito- 
ry organ, possibly the system of semi-cir- 
cular glands, which is directly affected by 
the oscillations of a vessel at sea, and which 
acts as a stimulus to the vomiting center. 

With regard to the nature of the move- 
ment, it may be pointed out that it is one of 
sudden descent, as any one may prove for 
for himself by trying a few experiments in 
a lift. I have certainly noticed a peculiar 
sensation in my ears, synchronous with the 
sensasion in the epigastrium, on the sudden 
downward movement of a lift, and experi- 
enced no sensattons on the upward move- 
ment. It is conceivable that these sudden 
and unexpected movements may take the 
endolymph in the semi-circular canals, so 
to speak, unawares, and create a condensa- 
tion or rarefaction, or both alternately, in 
one part or another of the labyrinth, there- 
in- altering the pressure on the endings, and 
thus causing a direct stsmulus to vomit. 

The routine treatment adapted for com- 
bating seasickness is compatible with this 
theory, as it mainly consists in lowering the 
sensibility, or the conductivity of the affer- 
ent nerves, or in numbing the vomiting 
center by the action of such drugs as pot- 
assium bromide, chloral or morphine. 

The Effect of IMcotlne Upon the Cardio- 
vascular System. 

Grassman 'Munch. Med. Wocheu.), 
from the vast amount of literature 
upon this subject combined with his person- 
al experience makes the deduction that the 
use of tobacco produces serious conditions 

in the cardio-vascular system. Its use 
during the age of development is given as 
one of the potent causes for arterio-sclero- 
sis. This process takes place more in the 
peripheral arteries at first; later after the 
prolonged use the heart muscle becomes af- 
fected. This is exhibited by the increased 
pulse rate, the arrythmia, and the tobacco 
angina. The duration of the use of tobac- 
co is more an important factor regarding 
the condition of the heart muscle than the 
subjective symptoms. Positive objective 
symptoms, however, as shown by Traube, 
can be demonstrated in the form of con- 
stant increased pulse rate, increased blood 
pressure, and hypertrophy of the heart. 
That nicotine poison has actually produced 
chronic myocarditis has been proven by 
Rosenbach, Faverger, Lewin, Kunkel. The 
history of the use of tobacco is present in 
nearly every case of organic disease of the 
heart muscle. The author pleads for a 
more serious consideration of these symp- 
toms from the use of tobacco, and advo- 
cates an earnest discouragement by the pro- 
fession for the indulgence in this pernicious 

Now Treatment for Rabies. 

Remlinger, director of the hydrophobia 
institute at Constantinople, has recently an- 
nounced the discovery of a new treatment 
for for rabies (Revue scientifique). The 
procedure consists in a vaccination made 
with mixtures of anti-rabic serum and of 
the fixed virus, already studied by Marie. 
The serum is obtained by injecting ascend- 
ing doses into the sheep, of fixed virus; at 
first into the jugular vein and next under 
the skin. He ascertained the perfect harm- 
lessness of this mixture when injected un- 
der the skin of man by experiments mader 
upon himself. The immunization in rab- 
bits was only temporary but in dogs it lasted 
for a year or more. The author has great 
hope that the immunity obtained in the 
sheep dog indicate a possible future for this 
new treatment. 


The Mature and Treatment of Dropsy. 

Dr. Thomas Hunt Stucky, A. M., M. D., 
Louisville, Ky.,says the term dropsy is one 
which is rather loosely applied to any ab- 
normal accumulation of watery fluid in the 
body. In more concise technical language 
we use the word edema when the fluid oc- 
curs within the interstices of tissue and as- 
cites when it is free in the abdominal cavity. 
For accumulations in other cavities special 
names are used, as hydrothorax, hydroperi- 
cardium, hydrocephalus, etc. 

Kdema of the subcutaneous cellular tissue 


4 l > 


Assures Normal Opsonic Index, Full Elimi- 
nation of Waste. Rich Red Blood. Cell 
Stimulation and Complete Nutrition. 

BOVININE. Internally it establishes a normal balance between elimi- 
nation and nutrition, result being health. 

BOVININE. Contains every element in a full and proper proportion 
necessary to completely feed every tissue of the human body. 

BOVININE. Has no competition, as all other prepared and liquid 
foods feed only in part, hence their field of usefulness is limited and 
nature must accomplish the rest, and this she can seldom do. 

BOVININE. Is not antagonistic to any medication, but greatly aids 
the therapeutic action of drugs. It is indicated at all ages and in all 

BOVININE. Locally as a dressing in all forms of ulceration or any 
peripheral starvation is ideal. 

BOVININE. Is ready for immediate assimilation, does not disturb, but 
gives the gastro- intestinal tract full and complete rest. 

BOVININE. Is rich in assimilable organic iron and is sterile. 


75 West Houston St.. New York City 

is a very common form of dropsy; it is usu- 
ally confined to certain regions, but may 
become general, in which case it is referred 
to as anasarca. The site in which edema 
most frequent occurs is in the feet and ank- 
les, next to this is the region about the 
lower eyelids. 

In a normal state of health there constant- 
ly exudes from the blood vessels, especially 
the capillaries, a fluid derived from the se- 
rum of the blood. This percolates between 
the cells of all tissues, and is the means of 
carrying nourishment to all those cells 
which are not in direct contact with blood 
vessels. These interstices between the cells 
are drained by the vessels of the lympphatic 
system, which are able to carry off easily 
all the fluid which comes to them under 
ordinary circumstances. 

The composition of this lymph is very 
nearly the same as that of the serum of the 
blood. It contains a larger proportion of 
water and only about three percent, of pro- 
teids. As a rule it contains no fibrin, al- 
though it will coagulate upon the addition 
of fibrin ferment, showing the presence of 
some of the fibrin elements. Its specific 
gravity will average about 1.015. 

Cohnheim taught that most important 
factor requisite to the production of dropsy 
is malnutrition of the walls of the blood 

vessels. It is well to keep this in mind, for 
although in most cases the other causative 
agents are much more evident yet this ele- 
ment of malnutrition will almost certainly 
be found to exist in a greater or less degree. 
It can readily be imagined that the single 
layer of delicate cells which form the wall 
of the capillary vessels would be. very sensi- 
tive to changes in the blood which is con- 
stantly passing them. In diseases of the 
kidneys, the liver and other excretory or- 
gans a number of poisonous matters accum- 
ulate in the blood to an abnormal degree, 
and they can not fail to harm this lining 
membrane. Fevers of all kinds, the pres- 
ence of bacteria, pus or other products of 
microbic invasion will produce the same 
effect. Of course, in these diseases we do 
not often have dropsy, but the endothelial 
membrane is in a weakened condition, and 
a comparatively slight determining cause 
will bring on this symptom. 

An excess of blood in the part may pro- 
duce an edema. When it is caused by 
overdistention of the arteries the liability 
to edema is not so great as when there is a 
venous stasis. In the former case the cap- 
illaries are constantly receiving plenty of 
fresh blood, while in the latter the same 
blood remains in the vessels and the endo- 
thelium derives but little benefit from it. 



Valvular disease of the heart is one of the 
main causes of a general slowing of the 
blood current and especially of the venous 
stasis. The pressure from behind, the vis a 
tergo, of the blood in the veins is never great 
under the best of circumstances, and when 
the power of the heart is weakened from 
any cause this propelling force is reduced to 
a very low point. In valvular disease of 
the heart the amount of blood passed through 
this organ is diminished until a compensa- 
tor}' hypertrophy is established. In the 
meantime the blood in the veins being im- 
peded to some extent in front and not forc- 
ed from behind, flows very sluggishly. 

In the legs the blood has to mount some 
distance against the force of gravity, which 
greatly retards the circulation. While the 
patient walks about vigorously the contrac- 
tion of the muscles of the legs, by pressing 
upon the vessels, helps to force the blood 
forward; but such patients can rarely walk 
with any great amount of vigor, the blood 
does not receive this extra help, and an 
edema of the feet and ankles is almost sure 
to be seen at some stage of the case. At 
first this is merely a puffiness observed at 
night after being up all day. The condi- 
tion spreads from the feet up the legs, be- 
coming greater as the case progresses. After 
a time the swelling is not entirely reduced 
even after a night's rest; the parts feel cold 
and pit upon pressure, the dents remaining 
for quite a length of time. Unless the case 
is treated properly this edema will finally 
involve a large portion of the body, it is an 
expression of extreme weakness of the cir- 
culation, and is rightly regarded by the laity 
as a very grave symptom. 

Allied to this condition in certain ways is 
the accumulation of fluid in the abdomen. 
This escapes from the vessels of the mesen- 
tery and intestines; it is seen in conjunction 
with dropsy in other parts, and may come 
from the same state of cardiac weakness 
which causes edema of the feet. In many 
instances, however, it has a special cause 
in an obstruction to the flow of blood 
through the liver. As is well known, all of 
the blood from the stomach, small intestine 
and most of the colon is gathered up into 
the portal vein and goes through the liver. 
Whenever there is any obstruction in this 
organ the blood is dammed back into the 
other viscera and its fluid oozes out into the 
general peritoneal cavity. 

A state of inflammation of the liver, bring- 
ing an abundance of leucocytes to the or- 
gan and causing a swelling of its cellular 
portion, produces a compression of the 
blood vessels, thus impeding the circulation. 
In chronic inflammations the overgrowth of 
the connective tissue has the same effect but 

Continued PAoe 52 




Original Communications. 

State Maintenance for Epil- 
eptics, by T. P. Satter- 

white. M.D., Louisville, Ky. 1 

Malignant Diseases of the 
St miaeh. Diagnosis in 
the Ear.y Stages, by Dr. 
M J. Payne, Staunton, 
Virginia 2 

Gangrenous Kidney. Trans- 
paritoneal Nephrectomy; 
Recovery, by Dr. Joseph 
Graham', M, D., and E. A. 
Abernathy, M. D. Dur- 
ham. N. C, 5 

Strangulated Hernia in In- 
fants, by John Egerton 
Cannaday, M. D.. Hans- 
ford, W. Va, Surgeon-in- 
charge, Sheltering Arms 
Hospital 6 

Hemmorhagic Malarial Fe- 
ver; Report of Cases, by 
P. A. Webb, M. P., Cal- 
vert, Alabama 8 

Some Clinical and Practical 
Points about the Prosoata- 
tiker and Prostatectomy, 
by Robt. C. Bryan, M.D., 
Richmond, Va 9 

Surgery and the General 
Practitioner, by J. W. 
Ellis. M.D., Lampas, Tex. 14 

The Relation of the Physi- 
cian to the Public, by V. 
Berry M. D., Wetumka, 
Okla'maho 16 


The State Hospital for Con- 
sumptives 21 

A New Director for the 
State Laboratory of Hy- 
giene, Raleigh 21 

Thompson Hospital 21 

Electiors, • 21 

Greensboro Cottage Sani- 
tarium 21 

Plague in San Francisco,.. 22 
Tri-State Medical Associa- 
tion '<■'- 

The Medical Brief Changes 

Hands 22 

Society Meetings 23 

Nalle-Maver 24 

Dr. J. F. Beall, 24 

Dr. S. M. Deal, Blacks- 
burg, S. C 24 

Dr. Geo. F. Shrady 24 

Dr. H. P. Loomis, 25 

Dr. Nicholas Senn, 25 

Review of Southern Medical 
literature, 25-29 

Book Notices. 

Journal of the Elisha 
Mitchell Scientific Society 30 

When Things Were Doing, 
by C. A. Steere 30 

Modern Medicine, by Wil- 
liam Osier, M D 30 

Diseases of the Nose and 

Throat, by D. Braden 
Kyle, M. I) SO 

Atlas and Text-book of Hu- 
man Anatomy, by Sabotta 
and McMurrich 31 

The Treatment of Frac- 
tures, Chas. L. Scudder. 
M. D., 31 

The Principles and Prac- 
tices of Modern Otology, 
by John F. Barnhill. M.D. 31 

Sexual Instinct, by James 
Foster Scott, A.B..M.D., 
CM 31 

Empire Builders, by Fran- 
cis Lynde, 32 

Maternity, by Henry D. 
Fry, M. D 32 

The Race for the Emperor's 
Cup, by Py Paul Eve 
Stevenson, 32 

The Mind of the Master, or 
The Nervous System of 
Jesus, by Salvarona, . . 32 

The Physician's Visiting 
List for 1908, by Blakiston 
Son's Co., 32 

Anarchism and Socialism 
by Geo. Plechanoff An-' 
derson, 32 

The Republic, by N, P. H. 
Kerr & Co 32 

Marxian Economics, by 
Ernest Untermann, 32 

Merck's 1907 Index, by 
Merck' Co 32 

Wellcome's Excerpta Ther- 
apeuta, bv Burruoghs 
Wei loomed Co., 33 

International Clinics, by 
W. T. Longscope, M. D.. 33 

Transactions or the In- 
diana State Medical As- 
sociation, by Dr. A. W. 

Brayton, 33 

Squibh's Materia Medici 
by F R. Sjuibb & Sou, 33 


Pain and Blood Pressure.. 19 
Wine and Typhoid Fever. . 19 
Frequency of Tuberculosis 

in Infancy 19 

Diphtheria, Irregelarity of 

the Pulse in 29 

Anastomosis Between the 
Commou Bile Duct and 
and the Duodenum for 
Obstructive Jaundice, .. . 20 
The Diagnosis of Chronic 
Valvular Disease of the 

Heart 33 

Inguinal Hernia in Children 33 
The Resection of Large 
Nerve Trunks Without 

Paralysis 33 

Medical Egotism 34 

Blood Pressure in Fevers, 85 
A Case of Land Scurvy, 35 
An Operation for Embolus, 35 
A Case of Cerebellar Hem- 

morrhage, 36 

Attempted Induction _ of 
Abortion by Intra-uterine 
Injection of Febling's 
Solution 36 

Indications for Rupture of 

the Membranes 37 

Acute Torsion of Both Fal- 
lopian Tubjs, 38 

Right-Angled Contraction 
of the Tendon Achilles 
as a cause of Stumbling, 

Etc . in Children 38 

Intraperitoneal Injection of 
Oxygen for Tuberculous 

Ascites 39 

Intraparietal Hernia with 
Very Small Peritonal Op- 
ening, Giving Rise to Se- 
vere Abdominal Pain. ... 39 
On the use of Massage and 
Movement in the Treat- 
ment of Fractures 40 

The Intracellular Occur- 
rence of Tubercle Bacilli 

in the Sputum 40 

Acetonaemia in Children.. 40 
The Aetiological Diagnosis 

of Typhoid Fever 41 

Acute Miliary Tuberculosis 
Following Intubation of 

Larynx 41 

Nasopharynx as Infection 
Carrier in Cerebrospinal 

Meningitis 41 

The Practical Application 

of the Demonstration of 

the Sphirochaeta Pallida, 42 

The Operative Treatment 

of Inguinal Hernia in 

Children 41 

The Microbe of Whooping 

Cough, 43 

Differential Diagnosis Be- 
tween Renal Disease and 

Perityphitis 43 

Pathology of Phlegmasia 

Alba Dolens 43 

Mobile Kidney with a De- 
scrip io i of an Operation 
for Anterior Nephro- 
pexy 43 

Tuber, ulous Diseases of the 

Aesopbagus and Stomach 44 
Diagnosis of Epidemic Cer- 
ebrospinal Meningitis 

in Infants 45 

A Case of Xerod -rma Pig- 
mentosum Without Pig 

mertation, 45 

The Treatment of Typhoid 

Bacilli Carriers, 45 

The Treatment of Malign- 
ant Growths With Or- 
ganic Extracts, ... 45 

Action of Morphine Upon 
the Genital Apparatus of 

the Woman, 46 

The Thymus and Death in 
the Course of General 

Anaethesia, 46 

The Suprarenal Glands 46 

The Origiu of Seasickness, 48 
The Effect of Nicotine Upon 
the Cardio- Vascular Sys- 
tem, 48 

New Treatment for Rabies, 49 


it is carried to a greater degree. In this 
the lumen of the blood vessels is 
sometimes almost obliterated, and it is in 
such cases that we find persistent dropsy in 
the abdomen. 

In diseases of the kidneys a large propor- 
tion of the poisonous matters which these 
organs should excrete are allowed to remain 
in the blood. These injure the walls of the 
capillaries, as referred to above, and the 
dropsy first seen in these cases is probably 
purely from this cause. Later on these 
same poisons affect the force of the heart 
muscle and weaken the nervous system, so 
that we may readily see how a part of the 
general anasarca sometimes observed in 
such cases may be due to circulatory weak- 


The general treatment of these cases de- 
pends, of course, largely upon the cause. 
Where the heart alone is at fault the patient 
should be put to bed, or at least confined 
to a chair if he can not lie down with com- 
fort, as frequently happens. Efforts must 
be made to increase the nutrition of the 
heart muscle and the efficiency of its nerve 
supply. To this end we must attend to his 
diet; such patients have a poor digestion 
and are often afflicted with diarrhea. The 
most nourishing and easily digested foods 
must be given, in as great an amount and 
at as short intervals as he can digest them. 
Tonics for the heart and nerves must be 
administered, but care and judgment must 
be observed in their use, for there is grave 
danger of stimulating the heart beyond its 

Digitalis and strychnine are powerful 
drugs, and their effects must be watched 
constantly. I have had better results with 
a preparation called anasarcin, which is a 
combination of several mild tonics, altera- 
tives and diuretics. It is a much safer drug 
to leave with the patient, and is very reli- 
able in its action; its diuretic effect is one 
of the best means of reducing the dropsy. 

Cases of renal dropsy are frequently 
helped l>v the saline purgatives and by any 
measures which increase the amount of per- 
spiration. The poisons which should be 
eliminated by the kidney can in a large 
measure escape through the bowel and the 
skin, and these means must be used to the 
point of endurance. As the circulation is 
always weak it is necessary to administer 
cardiac and general tonics, and for these 
patients the same drug, anasarcin, is prob- 
ably more efficacious than any other. 

I or dropsy into the abdomen the diuretic 
action of anasarcin and its tonic effect 
make it the remedy on which I have de- 

The Pretty Nurse. 

"Professional nurses have no business 
being so confoundedly good-looking," said 
a young man who has recently spent sev- 
eral weeks in a local infirmary. "The 
nurse who was delegated to attend to me 
while I was laid up was a distractingly 
handsome girl, with a pure Greek profile, 
reddish-brown hair — the kind that seems 
full of little golden tendrils in the sunlight 
— and eyes as liquid as a fawn's. The first 
time she put her finger on niy wrist my pulse 
ran up to at least 175, and she took it for 
granted I had a high fever and dosed me 
accordingly. I tried repeatedly to lure her 
into conversation, but she wouldn't be 
lured. She was strictly business. When I 
started to pay her compliments she would 
ask me to put out my tongue, which was an 
insurmountable obstacle in conversation. I 
used to lie there with my tongue hanging 
out, trying to put my whole soul into my 
eyes, but it was no go. No man can look 
romantic with half a foot of furry red ton- 
gue protruding from his countance. 

"Another way she had of gagging me 
was by putting the themometer in my 
mouth. The last week I was there I pro- 
posed to her five times, or, rather, I tried to, 
but she invariably choked off my declara- 
tions by thrusting a thermometer into my 
mouth. I got so excited one time that I 
came near swallowing a thermometer worth 
several dollars. She was a most excellent 
young woman and had lots of sound com- 
mon sense, as was evidenced by the fact 
that she gave me no encouragement what- 
ever." — The American Phvsician. 

One of the important points in anesthesia, 
which is not frequently forgotten, is to de- 
termine before its induction whether the pa- 
tient can breathe freely through his nostrils. 
Nasal obstruction will prove more or less of 
a barrier to efficient anesthetization, and 
under these circumstances it may be advis- 
able to let the patient inhale the anesthetic 
by way of the mouth, this being facilitated 
by placing a prop between the teeth. 

Before incising a pharyngeal abscess 
through the mouth a small, hard pillow 
should be placed under the patient's shoul- 
ders, so that the head will drop back suffici- 
ently to prevent the pus from flowing down- 
ward. — International Jour, of Surg. 

Owing to the great in frequency of primary 
tuberculosis of the bladder, it is important 
in every case in which this disease is sus- 
pected to look for a tuberculous focus in 
some other part of the urogenital tract. — In- 
ternational Journal of Surgery. 



In every case of severe contusion of the 
lower abdomen it is advisable to determine 
the condition of the bladder by passing a 
catheter. If nothing can be withdrawn, or 
only a small amount of blood, there is rea- 
son to assume a rupture of the bladder. On 
the other hand, evacuation of a large 
amount of bloody urine would point to a 
rupture of the kidney. — International Jour, 
of Surg. 

Although a rigid abdomen is generally 
characteristic of peritonitis, this applies on- 
ly to the early period of the disease, since 
in the later stages or in the severe septic 
from there is a tendency for the abdomen to 
again become soft and palpable without 
pain. — International Jour, of Surg. 

Torsion of the testicle is often difficult to 
diagnose from epididymitis and orchitis. 
The chief points in favor of the former are 
its suddenness of development, the early age 
of most patients, and the absence of any 
signs of gonorrheal infection of the urethra 
or prostate. — International Jour, of Surg. 

When making digital pressure for the ar- 
rest of postpartum hemorrhage the aorta 
should be pressed directly against the spine 
with the ulnar side of the clenched hand. 
The pressure should be shifted over the area 
occupied by the aorta, so as to avoid any 
damage to the sympathetic nerve plexus. — 
International Jour, of Surg. 

If possible, dranage should be avoided 
in operating for tuberculous disease of the 
bones, as the insertion of drains encourages 
the formation of sinuses. Scrupulous asep- 
sis will generally render the use of drainage 
unnecessary. — International Jour, of Surg. 

Dr. Archibald E. Baker, 126 Rutledge 
Avenue, Charleston, S. C, announces to 
the Medical Profession that after the first of 
January nineteen hundred and eight, he 
will confine his practice exclusively to 
General Surgery, Gynecology and consulta- 
tion work. — International Jour, of Surg. 

Used In Miscarriage- Just What was 

I find your II-M-C hypnotic anesthetic 
just what I have wanted for some time, and 
will keep a supply always on hand. In 
miscarriage where the placenta must be re- 
moved under anesthesia they are the very 
thing and relieve the operator of the worry 
of chloroform or ether. 1 believe them su- 
perior to the morphine and atropine hypo- 
dermic as more lasting and certain in ef- 
fect. DR. A. D. BARNETT. 

Guilford, Mo. 


to understand why dis- 
criminating physicians 
prefer Hydroleine to all other forms 
of cod-liver oil. It's the one emul- 
sion that is prepared by physiologi- 
cal methods to meet physiological 
needs. It is more digestible, more 
absorbable, and more utilizable than 
any other emulsion. It's pancrea- 
tized, of course; but that's only half 
the story. Write for literature and 
sample. Sold by all druggists. 


Sole Agems. 
115-117 Fulton Street. New York. 

H-M-G In Texas. 

I used Hyoscine Morphine and Cactin 
Comp, upon two tough cases, one an old 
man of sixty-five, with renal colic; and al- 
low me to go on record as saying it relieved 
him completely within fifteen minutes. The 
other was a Mexican who had had singul- 
tus for three days and I had given all of 
the remedies I thought of, read or heard of 
with no results. He was growing worse. In 
just three minutes after this first dose he 
stopped hiccoughing to stay stopped. 1 am 
inclined to the belief that H-M-C Abbott 
will be a greater boon to humanity than 
chloroform or ether because of its so much 
wider range of usefulness. 


Hondo, Texas. 

The Alkaloldal Treatmet of Pneumonia. 

In patients with a full bounding pulse 
and a hot dry skin — sthenic cases — begin 
treatment with aconitine, veratrine and dig- 
italin (Deferescent Comp. No. 1 ) ; or in pa- 
tients having a small, quick, thready pulse 
and a hot dry skin — asthenic cases — give 
aconitine, digitalin and strychnine (Dosi- 
metric Trinity No. 1). One granule of the 
combination selected should be given every 
15 to 30 minutes until the pulse softens or 
the patient commences to sweat freely; then 



one every half-hour to one hour as needed 
to maintain this effect. Keep the pulse at 
80 or under if possible, Envelop the entire 
thorax i and from chin to low on the hips) 
in a thin, close fitting jacket, thickly 
"quilted" with a raw cotton, or the com- 
mon "batten," well greased. If pain calls 
for treatment give a few doses of bryonin 
or hyoscyamine and codeine singly or in 
combination as indicated. Always secure 
complete deferescence and rest, no matter 
how much drug is required. Some cases 
do better on the above formulas alternated. 
Threatmeut should always be adjusted to 

Clean out the primae viar with 1-6 grain 
doses of calomel and podophyllin half hourly 
until one grain of each is taken; heaping 
teaspoonful of Saline Laxative in hot water 
and repeat every half hour till bowels move 
freely; then give one or two 5-grain tablets 
(usually one) of the Compound Sulphocar- 
bolates — Intestinal Antiseptics W.A. — ev- 
ery two hours; or enough combined with 
occasional doses of Saline Laxative to keep 
the bowels sweet and clean. If stools are 
malodorous after they cease to be dark (al- 
most black) in color, calcium sulphide 
granules, gr. 1-6 each (12 to 36 in divided 
closes daily) q. s, should be used as a sys- 
temic antisepsis is of the utmost impor- 

If seen early and properly selected reme- 
dies are pushed rapidly, nearly every case 
may be aborted. If the patient is naturally 
weak and has a rapid, and thready pulse 
instead of a full, bounding pulse, always 
give strychnine arsenate in place of a vera- 
trine. Codeine may be used to quiet cough 
if required, and emetine to facilitate expec- 
toration. Apomorphine in small doses for 
expectorant and relaxant effect often works 
best of all. If the pneumonic condition 
exists in a very young or very old patient 
and he does not cough and clear the the 
bronchial tubes sufficiently, the stimulating 
expectorant, sanguiuarine nitrate, should 
be used in just dose enough to produce 
sufficient coughing to rid the bronchial 
tubes of accumulated secretions. The com- 
plicating bronchitis may be as dangerous 
as the pneumonia itself. In such cases 
Calcinined (iodized calcium ) is an exceed- 
ingly valuable remedy: furthermore, noth- 
ing can excel it for delayed resolution in 
any case. For the heart, strychnine has 
long been our sovereign remedy, but for 
heart waverings, in the earlier stages, we 
strongly advise the substitution of cactin, 
gr. 1-67 (one or more as needed), in place 
of strychnine. Later on, in cases foolishly 
allowed to run their course, the whip, 
strychnine, may be needed; and when 
rightly used will often proved a life saver. 

It is of the greatest importance in all at- 
tacks of pneumonia to have a hyperleuko- 
cytosis present. For the production and 
maintenance of this physiologic state, Nu- 
clein, Abbott, is the greatest known rem- 
edy. In the milder cases give 20 to 30 
minims every four hours by hyperdermic 
injection into the deep muscular tissues. 
Nucleiu not only produces hyperleukocyto- 
sis, but it acts as a powerful stimulant to 
ever}- cell of the body. 

In all cases leave the patient on strych- 
nine or the Triple Arsenates with Nuclein, 
and occasional doses of cactin for the con- 
valescent period, and continue the Saline 
Laxative and Intestinal Antiseptics that 
you have used throughout the case, q. s., 
as required. 

The gist of the whole thing being; Forced 
deferescence, elimination, intestinal disin- 
fection, local protection and strong support 
to nature's fighting forces. — Abbott, in 
Clinical Medicine. 

Tho Origin of the Facial Nerve. 

Iiarman (Brit. Med. Jour.) combats the 
theory advanced by Mendel in 1887 that the 
nerve supply of the facial musculature did 
not spring from the seventh nucleus alone, 
but contains a partial contribution from the 
oculo-motorius nucleus as well. The au- 
thor's anatomical researches show that in 
the early verbebrates there is no facial mus- 
culature. With the development of eyelids 
and nictitating membrane, first observed in 
the sharks, the nearest available muscula- 
ture is adapted for the service of these new 
eye appendages; this musculature is the 
muscles of the spiracle ( the spiracle is the 
the first gill-cleft behind the eye, and has 
its representative in man in the ear tube). 
In those sharks which have a small devel- 
opment of eyelids the filching of the eyelid 
is of the smallest; in those sharks where 
the the eyelids and nictitating membrane 
are highly developed, nearly the whole of 
the spiracle muscles have gone over to the 
appendages, and the spiracle has become 
atrophied, and only remnants of the muscle 
proper to the lost gill can be traced. In 
these sharks the author traced the develop- 
ment of the spiracle musculature in a series 
of embryo the growth of the new eyelid 
musculature was followed. In all these 
fish the nerve supply could be traced from 
the conjoined nucleus of seventh and fifth, a 
nucleus known to anatomists as the facial 
complex. The progressive growth of the 
stolen spiracle muscles in the service of the 
face can be traced to their full development 
in the the facial muscles of man. From 
earliest to latest conditions they are arrang- 
ed in two layers, superficial and deep, and 
there is always a most marked intercommu- 




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short chapters on How to Prepare Top 
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nication of the many muscles of the face; 
in fact, the facial musculature is not made 
up of so many distinct muscles, but of two 
sheets of muscle which have many slips, 
and to these slips we give, for convenience 
of distinction, names, for example, orbicu- 
laris palpebrarum, levator anguli oris, or- 
bicularis oris, etc. The incorrectness of 
this separative nomenclature cannot be bet- 
ter shown than by citing the orbicularis 
oris, etc, which has been demonstrated to 
be nothing but the interlaced endings of the 
levator labii superiosis, depressor labii infe- 
rioris, levator anguli oris and buccinator 
muscles, and not a separate entity at all. 
Marman declares that the Mendel theory 
contravenes the above anatomical findings 
in these respects: ( 1 ) the splitting of the 
muscular sheets which are a morphological 
unity into arbitrary areas, ( 1 ) the shifting 
of a primitive nerve supply, and (3) the 
shifting of nerve cells from a cranial nu- 
cleus of one order to nuclei of quite a dif- 
ferent order. He therefore declares that 
Mendel is wrong. 

Plural Effusions and Its Treatments. 

Rarr (Brit. Med. Jour.) enters into an 
elaborate discussion of the physics of the 

pleural cavities, and then takes up the etio- 
logy of the disease. He believes, that every 
case is due to micro-organisms or their 
toxins. Those cases which follow cold or 
trauma have only thus been been rendered 
vulnerable. The vast majority of cases are 
tuberberculous, but some are rheumatic; 
due variably to pueumonocci, streptocci, 
staphylocci the B. coli, B. typhosus, or the 
organism of influenza. Even cases of dry 
pleurisy are frequently tuberculous, though 
not necessarily so. In such cases there are 
small effusion of plastic lymph, which is 
gelatinous in appearance and consistence, 
and contains a large number of cells with a 
relatively small amount of fibrin. This ef- 
fusion quickly organizes, and joins the 
two pleural surfaces together. In tubercu- 
luos cases accompanied by effusion there is 
not much fibrin, and even the cellular ele- 
ments may be small in amount. In pneu- 
mococcal pleurisy there is usually a large 
amount of fibrin whether there be much 
fluid or not. Those cases associated with 
streptococci staphylococi, and Bacillus coli, 
the fluid is very offensive. In cases of tran- 
sudation, the liquid contains a few endothe- 
lial cells and not much fibrin, and the spe- 
cific gravity is below 1,018. There are 



many cases, such as those arising in chron- 
ic Bright's disease, when the effused fluid is 
a mixture of a transudate and exudate. 
The questions of symptomatology and diag- 
nosis are passed over, and that of treatment 
is taken up. The author is not an adveate 
of too early tapping, and introduces air to 
take the place of a certain amount of the 
fluid— say one-half to three-fourths, lie 
completes the operation by throwing in, to 
contract the vessels and lessen secretion, 4 
c.c. of adrenalin sol. 1-1000, diluted with S 
or lo c.c. of normal saline. Salt should be 
eliminated from the diet. In cases of much 
effused fibrin, decalcifying agents, such as 
lemons, the citrates, etc., may be given. 
Injection of trypsin may hasten the solution 
and absorption of this fibrinous effusion. 
Injections of liquid paraffine may prevent 
adhesions. For empyema, the usual sur- 
gical intervention under eucaine anaesthe- 
sia is commended. The variety of organ- 
isms in the pus should be ascertained, and 
an appropriate vaccine, according the 
Wright method, should be employed. Cas- 
es of pneumo-thorax are best treated by 
drawing off the fluid and by filling the cav- 
ity with sterile air or oxygen. Tuberculous 
cases are the most troublesome, and usually 
when the fluid becomes purulent there is a 
mixed infection. The paper of Barr is in- 
teresting throughout and well worthy the 
attention of every medical practitioner. 

Subcutaneous Injections of Air as a Mean 6 

of Relieving Certain Painful 


Gubb's I British Medical Journal) expe- 
rience is based on seventy-seven cases of 
sciatica and several cases of neuritis of the 
brachial plexus, The summarized histories 
are given of nine cases of sciatica. In 
nearly all of them excellent results were ob- 
tained. The pumping apparatus consists 
of the double-bulb arrangement familiar in 
the Paquelin cautery. Its capacity should 
be known. The air is pumped through a 
glass bulb containing cotton, and enters the 
tissues through an irido platinum needle 
carefully sterilized. The skin over the 
painful area having been sterilized, the 
needle is inserted through the skin, and as 
soon as it is evident that no vessel has been 
punctured, the insufflation is commenced. 
A rounded swelling forms around the seat 
of puncture, and when the air reaches a 
vas.ular or nervous sheath it rapidly 
Spreads along it, and secondary swellings 
may Form at a distance. These secondary 
ramifications are specially apt to form in 
the limbs, where the sheaths are more num- 
erous. The skin at first becomes blanched, 
but this soon gives place to a pronounced 
reduess, which persists for some hours. The 

air takes several days to undergo complete 
absorption, and under the influence of mus- 
cular contraction travels far and wide, so 
that the characteristic crepitation of "sur- 
gical emphysema" may be felt at spots dis- 
tant from the seat of the original injection. 
Xo pain whatever is experienced, even 
when comparatively large quantities of air 
are injected, at most a sensation of disten- 
tion, "pins and needles," or pin pricks. 
Cutaneous sensibility is at once diminished, 
the skin becoming more or less numb. The 
needle having been withdrawn and the 
puncture sealed by a drop of collodion, the 
next step is to massage the part. The sub- 
cutaneous air must be alternately dispersed 
and brought together again, especially over 
the painful spots. This massage is an in- 
dispensable part of the procedure, and must 
be conscientiously carried out, indeed, pa- 
tients should be directed to repeat the pro- 
cess daily as long as any resonance remains. 
It is believed that the foregoing procedure 
causes elongation of the finer nerve ramifi- 
cations, where they leave the subcutaneous 
tissues to enter the derma proper. 

We call the attention of our readers to 
the advertisement of Robinson-Pettet Co., 
Louisville, Ky., which will be found on 
another page of this issue. This house was 
established fifty years ago, and enjoys a 
widespread reputation as manufacturers of 
high character. We do not hesitate to en- 
dorse their preparations as being all they 
claim for them. 


Journet ( La quiuzaine therap., ) has 
studied the interesting question of the treat- 
ment of diabetes by means of santonin, and 
states that under its influence the glycos- 
uria becomes rapidly diminished, the poly- 
uria becomes lessened, the patient's strength 
is increased, and the thirst and the dryness 
of the mouth are ameliorated. Santonin 
also possesses a stimulant effect upon the 
nervous system as well as an antispasmodic 
action, and, in view of the important role 
played by this system in the genesis of dia- 
betes, ought to diminish the glycogenic 
function of the liver. Santonin should be 
prescribed, just as are valerian, camphor 
and its bromide, and the various cyanides, 
in conditions in which we wish to lessen or 
prevent excessive muscular contraction and 
when we desire to restore to the nervous 
system its normal regulator action. Bire- 
age considers that this drug possesses an 
analygesic effect in the lightning pains of 
tabes and that its feeble toxicity permits its 
continued administration. 



The Excretion of Mercury by Syphilitica. 

Diesselhorst ( Berliner Klinisehe Woehen- 
sehieft) has tested numerous methods of 
determing the amount of mercury excreted 
in the urine of syphilitic patients undergo- 
ing treatment, and has found that the elec- 
trolytic method is both accurate and con- 
venient. The urine is concentrated by 
heating in vacuo and the organic substances 
present are oxidized with hydrochloric acid 
and potassium chlorate. As a cathode a 
small tube of gold foil 2-3 mm. in diameter 
and 2-2.5 cm. in length is used. The anode 
is of platinum. The current used was kept 
at .1-.05 ampere and the electrolysis was 
generally complete at the end of one day. 
The cathode is sealed in a glass tube with 
the capillary extremity into which the mer- 
cury is driven by heat and in which it is 
weighed. As a result of one series of ex- 
aminations the author found that mercury 
appeared first on the fifth day after begin- 
ning inunctions, increasing gradually while 
the treatment continued, and persisting. 
though gradually decreasing, after its ter- 
mination until at the expiration of two 
months after the last inunction only traces 
were present. The feces at first contained 
less mercury than the urine, but after the 
first month after the termination of treat- 
ment the feces contained as much or even 
more than the urine. Traces of mercury 
could be discovered in the urine and especi- 
ally in the feces of patients who had had 
their last mercurial treatment, years before, 
in the one case as much as ten years prev- 

The Limited Value of Diphtheria Antitoxin 
as a Prophylactic. 

Peters (British Medical Journal) refers 
to recent epidemics occurring in Notting- 
ham, in one of which he considers the results 
of the prophylactic use of antitoxin as dis- 
tinctly disappointing. In one, seven pa- 
tients developed the disease in spite of the 
serum out of twenty-one whose throats were 
proven (by cultures) to be infected by the 
bacillus. He claims that epidemics are 
sometimes large, sometimes small, and are 
susceptible of recovery just as is a disease. 
As antitoxin is rapidly excreted in the 
urine, there is a limit to the duration of the 
immunity conferred. The duration of im- 
munity was at first considered to be four 
weeks, later three, but the author believes 
that this period should be still further re- 
duced. At the end of three weeks if the 
epidemic continues, further injections are 
necessary. Increasing the average immun- 
ity does say 500 units would probably not 
increase to any extent the duration of the 
immunity. The author's general views as 
to the value of the antitoxin as a prophylac- 

can beAWIDED By employing 

in the treatment of inflammatory affections 
of the genito-urinary tract. 

The germicidal, inflammation-allaying 
and repair-augmenting potency of solutions 
of Tyree's Antiseptic Powder is a matter of 
common knowledge. 

The preparation is of distinct value in 
the treatment of both acute and chronic 
inflammatory affections of the urethra or 

Chemical and bacteriological analyses 
sent upon request. 


J. 0. TYREE, Chemist 
Washington. D. C 


tic will be understood by reference to the 
following statements: The procedures, 
then, of real importance in dealing with an 
outbreak of diphtheria are two in number, 
namely (1 ) bacteriological examination of 
throats, and (2) isolation of "carriers" of 
infection under proper medical supervision. 
Where both of these measures can be sys- 
tematically carried out, as is possible in 
most large towns, there is really no neces- 
sity for prophylactic injections of antitoxin, 
the latter procedure being in this case na- 
turally confined to the few whose throats 
are found to contain the specific bacillus. 
Even in these "carriers" there is no need 
to go to the expense and trouble where 
there is proper medical supervision, that is 
to say, a daily inspection of throats; for, in 
the first place, it has been pointed out that 
nearly all records will show a few cases 
where membrane developed in spite of an- 
titoxin, the general hospital "carriers" 
showing a third of such exceptions. Thus 
the conscientious medical man feels he is 
in no way relieved from the duty of careful 
inspection of throats. In the second place, 
we have such an efficient remedy in anti- 
toxin that there is practically no danger to 
the patient if the remedy is administered 
when the disease first declares itself. 



On the Use of Massage and Movement In 
the Treatment of Fractures. 

Cathcart (.Glasgow Med. Jour.) directs 
attention to the massage and movement 
method of treating feactures, and shows 
how almost every fracture in the body can 
have this method applied to it with much 
benefit to the patient, lie arrives at the 
following conclusions after a study of the 
literature and reviewing his personal ex- 
perience: Absolute immobility of the 
broken ends of bone is not essential to bony 
union. The ribs unite in spite of the move- 
ments of respiration, and wide experience 
has shown that the slight amount of move- 
ment, necessarily involved in the daily 
massage of a fractured limb, and in the 
daily active and passive movements for a 
few minutes, at least, of the adjacent joints, 
seems to hasten rather than hinder the for- 
mation and the s ilidification of the callus. 
Kxtravasated blood in joints and among 
muscles and synovial sheaths leads to ad- 
hesions in its neighborhood, as if it were in 
itself a source of irritation, apart from the 
irritation due to bruising and laceration of 
these soft parts which accompanies frac- 
ture. Massage in the form of stroking and 
gentle kneading and with it occasional 
movements, are in several ways beneficial 
in the treatment of fracture. These meas- 
ures not only aid the actual union of the 
bones, but help in the absorption of ef- 
fused blood and serum, restrain if not pre- 
vent the formation of adhesions among the 
soft parts, and maintain the nutrition of the 
muscles. They, therefore, simultaneously 
hasten union and prepare the limb to return 
to functional use, almost as soon as the 
bones are united. Splints and other reten- 
tive apparatus, including extension, are 
required more to prevent mal-uniou than 
non-union, and hence are called for, especi- 
ally where the weight of the limb or mus- 
cular action are likely to lead to bad posi- 
tion during the healing. Anyone suffici- 
ently careful and gentle in handling an in- 
jured and delicate part can do this massage 
and manipulation, the objects of which are 
in recent fracture to diminish the swelling, 
allay muscular spasm and soothe pain, in 
later stages to stimulate circulation, dis- 
perse accumulations of blood and serum 
and maintain nutrition of muscles, nerves 
and soft parts. The patient must be caused 
pain. The author then gives directions for 
the treatment of special fractures and calls 
attention to the fact that splints and exten- 
sion must be employed meanwhile to sup- 
ply the rest and fixation necessary. In 
certain fractures, as that of the clavicle, 
none of the appliances so for used prevent 
a certain amount of overriding; a good 
functional result is here obtained by the 

use of a simple sling with the arm firmly 
supported at the side. Simplification of 
apparatus is a desirable thing, and the 
writer is of the opinion that much can be 
accomplished in this direction. 

Modifications of the Structure of the 

Mammary Gland Due to Suspension 

of Lactation. 

Meynier (Riv. Crit. di Clin. Fed.) has 
made extensive experimental studies of the 
effects on the mammary glands of cats, rab- 
bits, etc., of sudden suspension of lactation 
at various periods after nursing has begun. 
The author found that there was a gradual 
formation of new connective tissue in the 
interlobular and interstitial spaces of the 
gland, but that the glandular acini were 
never compressed by it. At first the infil- 
trating leucocytes were mononuclear, then 
polynuclear. Early in the process of change 
there was an accumulation of milk in the 
gland and a tendency to resume the func- 
tion. Later the milk took on the charac- 
teristics of colostrum, and then atrophy be- 
gan. The epithelial cells contained small 
fat globules at all stages of the change. 
Some practical considerations derived from 
these results are these: When lactation 
has been suspended for a short time only it 
is possible to recover the function, and the 
best method is the systematic emptying of 
the gland. If the gland for any reason is 
not entirely emptied by the infant there is a 
tendency to return to the state of colostrum, 
which will cause dyspepsia in the infant. 
When mixed feeding is resorted to it is best 
to alternate the feeding and the nursing so 
as not to allow the milk to turn to colos- 
trum by too long stagnation. 

Plague In San Francisco. 

Plague is decreasing in San Francisco, 
and no additional cases have been reported 
since the middle of the month. There have 
been seventy verified cases, with forty-three 
deaths, thirty-two suspects are under obser- 
vation, seventeen patients have been dis- 
charged as cured, and ten patients are under 
treatment. — Med. Record. 

Pensions for Mothers. 

A lecturer of the University of Chicago, 
in a recent public address, advocated the 
pensioning of mothers by the State. The 
pension, he said, should increase in amount 
up to the third child, and then decrease 
until the advent of the sixth, when it should 
Med. Rec. 

The Charlotte Medical Journal. 



No. 2 

Achylia Gastrica. 

H. B. Kincaid, M. D., Mensphis, Tenn. 

The physician who is in the habit of us- 
ing the stomach tube for diagnostic pur- 
poses, frequently encounters a condition 
characterised by an entire absence of secre- 
tion of gastric juice, including HO, pep- 
sin, rennin, etc. Ewald in 1888 called at- 
tention prominently to this fact, under the 
name of anadeuia gastrica. Einhorn in 
1892 suggested the term Achylia Gastrica 
for the condition, by which it is now gen- 
erally so known. The disease may be 
either primary or secondary. The acquired 
or secondary form is found to exist in a 
variety of diseases, as in atrophy of the 
mucous membrane of the stomach, so fre- 
quently seen as the terminal stage of chronic 
gastritis. It it most generally associated 
with carcinoma of the stomach, but does 
not occur in all cases. It is easy to under- 
stand why achylia should exist when the 
entire mucous membrane is infiltrated or 
replaced by the new growth. But it is not 
so plain why there should be a suppression 
of secretion during the early stage, while 
the general nutrition is still unimpared, and 
where only a small localised patch of the 
mucosa is involved, as when sharply limi- 
ted to the pylorus, where normally no acid 
is secreted. Still more obscure is the re- 
markable fact, that an absence of gastric 
juice so frequently occurs in cancer of or- 
gans other than the stomach. Secondary 
achylia is almost constantly found in per- 
nicious anemia. It may also be found in 
splenic anemia, and other marked nutri- 
tional disorders. In the great majority of 
cases, a progressive atrophic gastritis may 
be found to exist. 

Atrophy of the glandular mucosa of the 
stomach and intestine occur in practically 
all patients suffering from pernicious ane- 
mia. The relation of the gastric atrophy 
to pernicious has been the source of much 
speculation and debate. At first it was 
held that the atrophy was responsible for 
the blood condition, but gastric atrophy 
does not always lead to pernicious anemia. 
On the other hand, pernicious anemia is 
encountered without any change in the 
gastric mucosa. When in fact, the latter, 
as a rule, ends fatally; the former need 
not necessarially endanger the life of 
the patient. To-day it is generally believed 
that both conditions are to some common 
toxic cause, instead of standing in the rela- 
tion of cause and effect. 

Symptomatic or primary achylia is not so 

serious a disease as the secondary form. It 
is characterised by the absence of anatomic 
lesions to explain the loss of function. Pos- 
sibly an individual peculiarity, or an in- 
herited functional debility. As many of 
these patients are constitutionally predis- 
posed to neurasthenia. Some clinicians 
deny that a true achylia ever exists as a 
purely functional disturbance, notwith- 
standing the fact, that there is no organ in 
the body so much under the control of the 
central nervous system as the stomach. 
That subacidity or deficiency of gastric se- 
cretion is a disease, there can be no doubt. 
It is universally admitted that a deficient, 
as well as an excessive secretion of gastric 
juice, is a most common functional distur- 
bance of neurotic origin. Accordingly 
then, I would insist that we may frequently 
find inhibitory influences of secretion, like 
subacidity, advanced to complete suppres- 
sion or primary achylia, of neurotic origin. 
Which condition is frequentlv not recogniz- 
ed in neurotics. The slightly disturbed 
general condition, dispite the apparent 
severity of the malady, together with the 
fact that the secretion of gastric juice some- 
times returns after a prolonged absence, 
also argues in favor of a neurotic or primary 
form. Various cases have been authenti- 
cally reported in which the HC1. secretion 
was restored after an absence of from on to 
five years. Recently I was much gratified 
to fine free HC1. in the stomach contents 
of a neurotic patient in whom, previously 
repeated examinations during a period of 
most a year had failed to reveal any. 

At first thought the failure of the stomach 
to secrete gastric juice would lead to the 
inference that the digestive functions would 
greatly suffer. Such however, is not al- 
ways the case. Einhorn reports one case 
that he had observed for four years, whose 
general condition, if anything, improved. 
Ewald treated a patient in which the secre- 
tion was absent for two and-a-half years, 
yet gaining forty-two pounds. I have ob- 
served a number of cases for one and two 
years, which have more than held their own, 
one having gained thirty pounds. How- 
ever, Lubarsch has correctly said, that 
those who have lost gastric digestion have 
one weapon less in the struggle for existence. 
And clinical experience teaches, that per- 
sons thus affected are more sensitive in 
general, and much more liable to gastric 
diseases. The secretion of HC1, being the 
normal disinfectant, largely protects the 
mucosa from infection. When achylia pa- 


tients are attacked by intestinal diseases 
and this supplementary digestion is inter- 
fered with, the prognosis becomes serious. 
It has been proven too, that the Jejunum 
is normally sterile, while in cases of achylia 
it swarms with bacteria. 

The symptions of achylia are not charac- 
teristic. When due to organic disease, the 
general symptoms of such disease will be 
usually present. 

In the achylia due toorganic disease of 
the stomach, as in cancer, the digestive 
disturbance is that of the primary disease. 

When associated with conditions of mal- 
nutrition, like pernicious anemia, the symp- 
toms due to the underlying cause usually 
overshadow those referable to the absence 
of the gastric secretion. 

Occasionally achylia gastriea exists in 
the neurotic without symptons, particularly 
when the motor function is well preserved, 
and the compensatory intestinal functions 
remain intact: but sooner or later distur- 
bances arise. Achylia patients of neurotic 
origin frequently complain of lessened ap- 
petite, a sense of fullness or oppression af- 
ter eating, inability to take large meals, and 
in many instances, of diarrhea. There may 
be headache, disturbed sleep, a feeling of 
fatigue, or lack of ambition. A variety of 
nervous symptoms are frequently associated 
with the above. Xausea and vomiting are 
unusual, but vomiting may occur in cases 
with motor deficiency. But as a rule hy- 
permotility exists, and the stomach empties 
itself much quicker than normally. 

In fully half of the cases intestinal symp- 
tom s sooner or later, make their appear- 
ance. Diarrhea is the most frequent bowel 
disturbance. Constipation may exist in 
some cases or alternate with diarrhoeal at- 
tacks. Many patients will give a history 
of diarrhea occurring at irregular periods, 
even for years. The diarrhea is character- 
ised by the fact that it occurs without 
straining and usually without pain, but 
there may be colicky pains, varying in Sev- 
ern v with the si/e and character of the 
meal. Occasionally the bowels move sev- 
eral times in rapid succession early in the 
morning. The stools are frequently large, 
and contain visible particles of undigested 
I""'!. A desire to evacuate the bowels soon 
meal is of frequent oc- 
currence. The reasons for the diarrhea are 

The fad lias been established that the 
closure and opening of the pylorus is regu- 
lated through the nervous mechanism of 
luodenum and stomach. The closure 
of the pylorus is due to a stimulating action 
of the hydrochloric acid on its mucosa, and 
it only opens when the alkaline intestinal 
secretion neutralises the acidity of the chyme 

in the upper duodenum. The escape of 
acid chyme into the duodenum again causes 
a reflex, which closes the pylorus. The 
disturbed mechanism of the pylorus or liy- 
permotility in achylia, is undoubtedly due 
to the absence of the acid gastric juice. 
Evidences of this fact is characteristic of 
achylia, as it is necessary, as a rule, to as- 
pirate an ordinary test meal, within half the 
usual time, to obtain sufficient contents for 

Pawlow has further proven that the acid 
gastric juice in the stomach and duodenum 
not only regulates the mechanism of the 
pylorus, but that its presence in the intesti- 
nal tract, acts as a normal, the most power- 
ful stimulant, on pancreatic and intestinal 
secretions, thus aiding intestinal digestion. 
The absence of gastric juice therefore 
means, a poor pancreatic secretion and im- 
perfect intestinal digestion, and it also 
means, that the pylorus is kept constantly 
open through which too large amounts of 
coarse and unprepared food may .so rapidly 
pass into the intestines, as to seriously im- 
pair its mechanical and chemical functions, 
by overtaxing an already embarrassed or 
inadequate intestinal digestion. Hence the 
diarrhea which occurs so characteristically 
in this class of patients. The importance 
of this form of dyspeptic diarrhea cannot 
be overstated. 

Cases of achylia may be devided into 
four classes, symptomatically. 

First, those without any gastric or intes- 
tinal symptoms. Cases belonging- to this 
group are exceedingly rare. I have one 
case under observation since April 1906. 
Second, those suffering from stomach symp- 
toms without any bowel disturbance. 
Third, those presenting intestinal symptoms 
only, while class four, includes those suf- 
fering from both stomach and intestinal 
symptoms. Excepting the first group, the 
following cases are illustrative of such 

Mrs. B. aged 35, had suffered from much 
gastric discomfort for three or four years: 
the distress often grew to a severe dull pain, 
lasting for several hours. Appetite fairly 
good, but refrains from eating to avoid dis- 
comfort . Frequent sense of oppression with 
eructations of gas, and sometimes of food. 
No nausea but occasional vomiting. Slight- 
ly constipated. Emaciated, weak and loss 
of energy. Sleep disturbed, and very nerv- 
ous. Frequent examinations of the stomach 
contents after usual test breakfast, reveal 
total absence of hydrochloric acid, pepsin 
and rennin. 

Mrs. ( ). aged l_\ History negative. 
Mild attack of acute gastritis, lasting about 
one week, five years ago. Heart and lungs 
intact. Right kidney palpable. For the 



past three years has suffered from frequent 
attacks of diarrhea, lasting from one to six 
or eight weeks, with but little relief from 
the usual diarrhea remedies. Sometimes 
acting from five to ten or twelve times daily, 
and often moving several times in rapid 
succession early in the morning. No 
straining and seldom any pains. Appetite 
usually good, but anything approaching a 
hearty meal, quickly provokes bowel move- 
ments as a rule. Xo nausea, vomiting or 
gastric distress. Headaches severe, though 
rare. Very nervous for six or eight years. 
Sleep undisturbed as a rule. Marked ema- 
ciation and debility during last year or so. 
Stomach found empty at usual time for as- 
perating test meal, but obtained sufficient 
contents for examinations, by aspirating 
earlier, and repeated analyses show an en- 
tire absence of IIC1, and ferments. While 
not conclusive, the only evidence present, 
shows the condition to be due to chronic 
atrophic gastritis. By judicious treatment, 
the patient has apparently enjoyed normal 
health for most a year. 

Mrs. Mc, aged 34, referred to me by Dr. 
Krauss, two years ago. History negative, 
except that frequent bowel movements had 
been induced by nervous shocks, at various 
times during her life. Always enjoyed best 
of health until twelve years ago, since when 
has suffered with various digestive distur- 
bances. As eructations of gas, spitting up 
food, fullness or distress after meals, vomit- 
ing without nausea, and frequent attacks 
of diarrhea, lasting often for several weeks. 
Usually induced by a hearty meal, or vari- 
ous articles of food, and frequently by 
fright or nervous excitement, also states 
that because of a constant fear, she invari- 
ably has a bowel movement when preparing 
to go anywhere, as for a drive, or to theatre. 
Fainting often accompanies the diarrhea, 
and usually occurs from an active purga- 
tive. Usual neurasthenic symptoms ab- 
sent, except digestive disturbances of 
stomach varied, characteristically of ner- 
vous dyspepsia. Headaches rare. Sleep 
undisturbed. Appetite irregular, and often 
absent. Despite numerous attendance and 
various treatments for twelve years, her 
health gradually grew worse. Losing 
thirty pounds in flesh, becoming greatly 
emaciated and debilitated. Many repeated 
examinations of the stomach contents al- 
ways revealed a total absence of HC1., 
pepsin and rennin. No evidence of any 
importance could be obtained, to distingu- 
ish this case from the primary form, yet the 
general neurotic condition was not charac- 
teristic. However, her normal weight, and 
general health have been fully restored, 
and apparently enjoying the best of health 
for quite a year. 

A positive diagnosis of achylia gastrica 
cannot be made from the symptoms alone. 
It is only, and readily established by a 
careful examination of the stomach con- 
tents. Cases in which the 1 1 CI. secretion 
is entirely absent, but in which every min- 
ute traces of pepsin or rennin is retained 
are not achylia in the strictest sense of the 
word, but are best classified as such by 
many clinicians. When achylia is found 
to exist, it is of first importance to ascertain 
the underlying cause. It often requires 
much care to distinguish the primary from 
the secondary form. When due to a neuro- 
tic condition, the evidences of organic dis- 
ease are absent, and the recognized neurotic 
condition would establish the cause. 

It is not my intention to go into the de- 
tails of treatment, but simply to emphasize 
a few of the most important points. Of 
first importance is the diet. It is of utmost 
importance that the food be broken into 
very minute particles, or can be easily di- 
vided by chewing. Vegetable food, as a 
rule, is very well born. Thick vegetable 
purees are most suitable. All food must be 
thoroughly cooked, especially meats, so that 
the fibers easily seperate. Meats are to be 
allowed only in small quantities, as they are 
in no way changed in the stomach, and 
reach the intestines in the shape they are 
swallowed. Connective tissue and tough 
fibrous meats must be avoided; likewise 
coarse fibrous vegetables. Careful division 
of food by thorough mastication is an es- 
sential of treatment. If the teeth are bad 
as they frequently are with digestive dis- 
turbances, the dentist's aid must be sought. 

( )f drugs, hydrochloric acid, caroid, pep- 
sin, and pancreatine, especially the former, 
are of value. While it is not possible to 
give sufficient HO. to equal the amount 
normally secreted, yet we may often give 
enough to greatly control the mechanism 
of the pylorus, as good results are frequent- 
ly had from smaller quantities. It is par- 
ticularly valuable in cases complicated with 
diarrhea. Owing to the fact that it is the 
normal or physiological stimulant to pan- 
creatic secretion. In some cases it also acts 
favorably on the nervous symptoms. 1 fre- 
quently administer from 30 to 70 drops of 
dilute HC1. after meals. Tinct of nuxvo- 
mica in large doses before meals may prove 
beneficial in some cases. The presence of 
undigested food in the colon, often results 
in considerable intestinal irritation, which 
may be overcome by colonic flushing. Gas- 
tric lavage is only indicated when much 
mucus is secreted. 


Nephritis. It occurs at all ages and in both sexes, 
H. H. .Mitchell, M. D.,Secty. Section on Medicine, bnt more often after middle life and males 
Southern Medical Association, Birmingham, are attacked oftener than females. This 
•^ a - can be accounted for easily as men are ex- 
This is a disease that has been discussed posed more than women, and occupation 
as much perhaps as any other. Quite a has quite a good deal to do with it. Per- 
great deal has been said regarding manage- haps exposure to cold and wet — men who 
ment and treatment, yet when we look over work in wet places and those who are con- 
tin- field we find them going on just the stantly in water are more susceptible to it 

r. I will not divide and classify as that is a very common cause, 

them for the management and treatment is Long continued use of alcohol predisposes 

usually about the same. to it, and is a very common cause. 

The onset in the different varieties is The exciting causes may be those acting 

nearly always sudden, but may vary some on the skin, such as cold, dampness, very 

with the exciting cause. extensive burns and chronic skin diseases. 

We usually have nausea and vomiting, Lead workers are subject to it and are of- 

some (dullness, pain in the back, pallor, ten attacked. Then we have auto-intoxi- 

edema of the feet and ankles, eyelids and cation from the inflections diseases — in my 

face puffed, often some fever, but rarely opinion scarlet fever is responsible for more 

high and does not run a regular course as of them than all the others put together of 

a rule. which might be mentioned typhus, typhoid, 

Where there is uremia, especially in chil- relapsing fever, small pox, cholera, diph- 

dren we may have convulsions. Often we theria, yellow fever, grip, measles, chicken 

don't find many of the local symptom's and pox, erysipelas, acute articular rheuma- 

without a close examination they may pass tism, pneumonia, cerebro-spinal meningitis 

us for a time unobserved. You may ex- and tuberculosis. 

amine the urine in any of the acure infec- In all these diseases we should be on the 

tious diseases today and find nothing, while lookout and examine the urine frequently 

tomorrow you may find large quantities of or we might allow it to exist too long before 

albumen. The eyes are often affected and we discover it. 

some ol them have a heart lesion. The I will not mention the pathology for the 

pulse at first is almost always hard and text books are well filled on that and are all 

tense and as a rule slow-later it will lose about together. 

some of its hardness and usually gets faster. The diagnosis should be easy when we 

If there is general ascites especially in very have any of the symptoms, and if a careful 

old patients we sometimes get a very rapid chemical and microscopic examination is 

pulse and one that is almost thready, which made. 

seems to point to an early death, but in this In all cases where there is pallor of the 

we will occasionally get a genuine disap- skin or puffiness of the eyelids, nephritis 

pointment for they will sometimes react and should be suspected and urinalysis made 

live for quite a while after with all the without delay if there is no other symptom 

symptoms markedly improved. present. 

Uremic convulsions are seen frequently In the very marked cases especially those 

in adtdts in the more severe types, not as following scarlet fever, when the patient 

often however as in children, these are developes headache, restlessness, muscular 

somel inns followed by very severe hemorrh- twitching, nausea and vomiting, a tense 

age. pulse, moderate fever, dropsy or anaemia 

Very mild cases may last from two to you can almost make a positive diagnosis 

four weeks and apparrently recover, but without going futher. 

wln-n exposed they are very liable to recur Slight albuminuria in pregnancy without 

from time to time and sometimes they have casts is not a true nephritis, still it is advis- 

the fatal attack and develop convulsions, able to watch them closely and treat them 

coma ami finally death closes the scene, as if they were true. In all cases the his- 

others may recur a number of times and tory plays a very important part in making 

gel through each attack and live for several a diagnosis. 

years. It is never safe to make a favorable pro- 
Nephritis in pregnancy differs from the gnosis, accept in the mild ones which are 
other somewhat, it comes on gradually and predisposed by exposure to cold, etc. Some 
the albumen increases from month to month of them will apparently get entirely well, 
until the eighth or ninth, and up to the time There are probably fewer of them gets en- 
of delivery, eclampsia is liable to occur, tirely well, following scarlet fever than any- 
but after delivery they usually make a rapid thing else. 

recovery, apparently without any kidney While a great many of them will get well 

changes. that are predisposed by the other diseases 


iii which they develop. 

When we find a general edema, dropsical 
effusion into the serous sacs, uremia if ac- 
companied with much cerebral manifesta- 
tions, such as convulsions or coma and in- 
flammation of any of the internal organs as 
pneumonia, pleurisy, pericarditis, meningi- 
tis, peritonitis, etc., the prognosis is cer- 
tainly very grave. 

Suppression of the urine for any time say 
thirty to forty eight hours I have noticed is 
a fatal symptom. 

Recovery is occasionally noted however 
where there is a large amount of dropsy 
provided there is no uremia present. So 
much for prognosis. 

The treatment in all cases of long stand- 
ing is very unsatisfactory as a rule. I al- 
ways try to relieve the congestion and in- 
flammation as well as the edema first and 
stimulate the different organs to their proper 
functions, for it must be born in mind that 
the bowels, kidneys and skin should be 
looked after closely and all kept thorough- 
ly open, absolute rest in a warm bed in all 
acute cases either mild or severe is impera- 
tive. Warm woolen underwear and kept 
between woolen blankets is very important. 
The diet should be bland in all cases, at 
first milk or (preferably with me) butter- 
milk if it is pure and fresh is the best diet 
if the patient bears it well. 1 invariably 
insist on their drinking freely of water or 
lemonade, or some of the mineral waters if 
taken in large quantities is beneficial. 

Later on I allow meat broths with rice, 
well cooked vegetable soups, oatmeal, grits, 
rice, stale bread, toast, macaroni, mashed 
potatoes, some stewed fruit, and sparingly 
of boiled or broiled fish — a little chicken 
etc., and have never had cause to regret it. 

I consider absolute rest worth more to 
them than anything else. 

I have never practiced blood letting in 
any form, but it is highly recommended by 
some and I believe there are cases where it 
is of inestimable value especially in those 
who suffer with much pain. Profuse per- 
spiration benefits a large number of cases 
by diminishing the edema, but has a ten- 
dency to weaken the patient. 

As the medicines we have nothing that 
will cure a true nephritis. 

The changes that has taken place in the 
kidney structure which results from several 
forms of nephritis cannot be replaced with 
healthy tissue and the only thing that we 
can even hope to do is to arrest, as it were, 
this destruction and build up the general 
system and if possible avoid any cause 
which might result in a recurrence. Quite a 
good deal has been given from time to time 
in the text books and medical journals on 
the medicinal treatment and we are com- 

pelled to give them treatment of some kind. 
To niy mind the treatment can be summed 
up as follows: tonics, diuretics, diaphoretics 
and cathartics, these can often be given in 
combination or separately as one may pre- 
fer. I have had the best results from digit- 
alis, either the fresh infusion (which per- 
haps is the best form to use > or a combina- 
tion of ext digitalis, ext. squillae and Ilycl, 
Cum Cretae. Some form of iron, I preper 
fresh Bashams mixt to any other I believe. 
Pilocarpine, elaterium, saline cathartics, 
sod, or mag, sulph, etc. 

The old 0/Vburnt sulph. of iron and wine 
has benefitted a great main — this if pre- 
pared by burning the copperas and powder- 
ing it finely and put a level tablespoonful 
in a qt. white grape wine and give table- 
spoonful tid, for two days leave off the third 
day and give small doses mag. sulph. 
enough to act freeh — then alternate as be- 
fore two days wine and one day salts, calo- 
mel is of great value-given occasionally. 
Strychnia or mix is indicated in almost 
every case, this I usually order three or four 
times a day, I will say that even- case is an 
individual one and must be treated as such. 

Convulsions are best controlled byinhala- 
tions of chloroform or chlor. Hyd. in mild 
ones sod. or pot. brorn. may control. Mus- 
cular twrtching by chlor. Hyd.Nitro, Give, 
and if too severe morphia. Regular habits 
and diet with good warm clothing probably 
does more for them than most anything 

Excesses oi Modern Times and Their 
Relation to Disease. 

By Marion McH. Hull, M. D., Atlanta, Ga. 

One of the most prevalent causes of im- 
paired health in this latter day is the indulg- 
ence in one or more excesses. We fre- 
quently have various forms of disease re- 
sulting from this cause whose symptoms are 
so complex that to describe them in detail 
would almost exhaust the list of known 
symptoms. For instance, there occurs to 
my mind as being very prevalent conditions 
nephritis, paresis, and gouty or rheumatoid 
conditions. It is not our purpose now to 
present an exhaustive study of how these 
originated, but to suggest in one or more 
instances the underlying causes and their 
development, hoping that it will held us to 
avoid such conditions in the future, by 
removing the possible cause now. 

Underlying all diseases are' four essential 
causes, as follows: Inherited diatheses, 
nutritive disorders, nerve reaction, and 
infectious. Rarely does one of these occur 
alone, but more often a combination of two 
or more becomes operative, and disease is 
the result. For example, take a child born 



of tuberculous parents; it is entirely possi- 
ble for that child to develop into the most 

us manhood and never have a sign 
of tuberculosis, even though it has an in- 
herited diathesis. Suppose, however, that 
about the age of puberty when the whole 
nervous system is under great strain to con- 
trol the functions properly, when the whole 
nature is undergoing a revolution, the child 
should eal some food which is difficult of 
digestion, a nutritive disorder would ensue 
and the resistance of the child be lowered. 

upposed this child at that time is in 
contact with tubercular bacilli exhaled from 
the lungs of a tuberculous parent. During 
all these years he has been inhaling this in- 
fected atmosphere, but has not developed 
the disease; now, because of the nerve reac- 
tion above spoken of, the disordered nutri- 
tion, with consequent lowered resistance, 
tin- bacilli gain foot-hold in a favorable soil 
furnished by the inherited diathesis, and 
the disease results. This we see that all 
four of these essential causes frequently 
enter into the etiology of a particular dis- 

Of these four causes, however, what most 
concerns us in our present study is the in- 
fluence exerted by nutritive disorders and 
nerve reactions. I propose to limit our dis- 
cussion to two particular diseases which are 
very prevalent, and of which, I feel con- 
vinced, excesses are very prevalent causes; 
1 refer particularly to arterio-sclerosis, with 
its multiform manifestations, and gouty af- 
fections. Take for instance, arterio-sclero- 
sis; it consists essentially of a degenerative 
condition of the arteries of the body, the 
elastic fibres at first undergoing a fatty de- 
generation, weakening the walls and sub- 
sequently a sclerotic or hardened condition 
taking its place, the normal resilient tissues 
being replaced by non-elastic tissues. Now 
various symptoms may result from this, de- 
pending upon the degree of sclerosis and 
the location of it. Sould the arteries of the 
kidneys be affected, the symptoms of neph- 
ritis would result. An improper elimina- 
tion of the products of metabolism which 
should be excreted by the kidneys would 
bring on a train of symptoms, which might 
produce subsequent heart or mental dis- 
orders. Should the arteries of the brain be 
affected, apoplexy would result, with im- 
mediate death, or hemiplegia with local 
softening of the brain; or paresis, might 
result with all its attendant train of symp- 
toms, [f the arteries of the heart should 
become affected, severe attacks of angina 
pectoris mighl follow. So you see that un- 
derlying a great many diseases is this con- 
dition of arterio-sclerosis. 

Most authors in writing on this subject, 
assign as the principal cause alcoholism or 

syphilis. Of course, these diseases may, 
and undoubtedly do, produce arterio-sclero- 
sis; but it has been my experience to treat a 
great many cases in which neither of these 
causes could be assigned; in fact, 90 per 
cent, could not be traced to either of them. 
In trying to account for the conditions, I 
have come to the conclusion that excesses 
of eating and of working, have been more 
responsible for them than the worship of 
Bacchus and Venus. Take' for instance, 
the matter of over-eating; we all over-eat; 
it requires an amount of food which will 
furnish three thousand calories to supply 
the demands of the body for twenty-four 
hours, and this should be in the proportion 
of about 100 grins, of proteid, 600 grms, of 
carbo-hydrates, and 60 grms, of fats. This 
would be furnished by about four ounces of 
meat, or three glasses of milk and two eggs; 
about six to eight thin slices of bread, an 
ordinary serving of potatoes and rice, a 
dish of cereal morning and evening; an or- 
dinary portion of butter at each meal; and 
from six to eight glasses of fluid in the 24 
hours. A cursory glance at this will show 
in a moment that we ordinarily eat too 
large a proportion of meat, drink too little 
fluid, and eat too little fruit; and on the 
whole eat a great deal more than is required. 
The effect of eating too much would be to 
require the system to do more work and the 
eliminative organs to overtax themselves in 
their attempt to get rid of the products of 
metabolism, which should be excrited. 
Where exercise is deficient the organs are 
not able to eliminate these products, and a 
general accumulation takes place. These 
poisonous products circulating in the blood 
have the same affect on the cells of the body 
as the poisons of alcohol or of syphilis. The 
cells forming the arterial walls are fed by 
blood ladened with poisonous products; de- 
generation takes place, followed by sclero- 
sis. In this way, excess in eating may 
cause arterio-sclerosis, which may manifest 
itself in nephritis, apoplexy, or paresis. 
This is not mere theory, I recall now, a case 
of a gentleman who was most temperate in 
every respect except in the matter of eating; 
he was an enormous eater, and died of 
apoplexy after a few hours illness. There 
was no other way to account for the sclero- 
sis in this case, except as above. I have 
also in mind a number of cases of nephritis 
which cannot be traced to any other origin. 
It is a matter of common knowledge that 
excesses in eating cause gouty conditions; 
so frequently is gout associated with the 
rich and overfed, that we have commonly 
supposed that it could not occur in the poor 
and underfed; which however is an error. 
In these latter, however, a different series 


of phenomena account for the error of 

Another one of the excesses which is ex- 
tremely common and which is a very pre- 
valent source of disease, is mental excess. 
By this I do not mean an excess of mental 
work only, but worry associated with work. 
Work wearies, but worry wears out. The 
fierce competition of modern times and the 
over-weaning desire to augment wealth has 
developed a condition of high tension, that 
eventually results in disease of this charac- 
ter. Let us see how this comes about; a 
man now-a-days gets up, dresses hurriedly, 
eats his breakfast in haste, not chewing his 
food properly and frequently at the same 
time planning his day's work, withdrawing 
the blood to the brain from the digestive 
organs where it is needed for proper func- 
tionating; he hurries forth immediately af- 
ter eating, and plunges head-long into a 
rush of w T ork. At lunch, tired and with 
deficient nerve power, he hurries home, and 
through another meal in the same fashion, 
and back to his desk. Then when evening 
comes he is very much exhausted, and not 
able to properly digest the food which he 
ingests; and going to bed with his business 
on his mind, is fortunate if he is able to rest 
quietly. The next day the same round is 
repeated. If he is of that happy disposition 
that enables him to accomplish his work 
without worry, he is able to stand this ex- 
haustive demand for quite awhile; but there 
are very few men who have that gift, and 
the little worries wear out the already over- 
taxed nervous system. Then the element 
of nerve reaction comes into play, and with 
insufficient nerve power, nutritive disturb- 
ances result, with increased formation of 
the product of metabolism, and decreased 
elimination, with consequent defective 
nourishment of the cells, with degenerative 
conditions, and sclerosis. This is not pure- 
ly theoretical either; fori have in mind at 
the present time several cases of this condi- 

We have advanced thus far, we have 
shown that the excesses in eating and in 
mental work with worry, are capable of 
producing disease, and we have shown how 
and why they do. It is not necessary to 
demonstrate that the more common and 
vulgar forms of excess would develop dis- 
ease conditions; so that we are prepared to 
take the next step — how it may be prevent- 
ed. 1 would suggest, first, that we can be 
more frugal in our meals than we have been 
in the past. I was recently at an institution 
where I had the pleasure of being thrown 
with a company of as fine a lot of men phy- 
sically and otherwise, it has been vay pleas- 
ure to see in many a day. Their breakfast 
consisted of a cup of coffee and of a bowl 

of oat meal, bread and butter, and boiled 
mutton; their dinner of chicken, baked po- 
tatoes, bread and gravy, and stewed fruit; 
and their supper of crackers and milk. 
Comparing this meal with what we ordin- 
arily indulge in, and comparing the vigor- 
ous physique of these young men with that 
of the pampered rich, we can but feel that 
the advantage is in favor of frugality; cer- 
tainly from an economical standpoint it 
would be so. Another thing we would learn 
would be that less worry and work would 
accomplish the same thing, if we combined 
with it a third suggestion, that I should 
like to make, that there should be more 
time given to outdoor exercise and recrea- 
tion. I believe a revolution would be 
worked in the health of our community, 
their lives would be prolonged and life 
made more joyous if a specified time would 
be given to recreation and rest. The out- 
door exercise would stimilate the excretory 
organs and improve the metabolism so that 
the various functions of the body would not 
be taxed beyond their powers. The nerv- 
ous system would be better, and improved 
health would result. I furthermore believe, 
that with the general health improved, a 
larger amount of business could be accomp- 
lished in a shorter number of hours; and in- 
stead of financial loss resulting from the 
time given to recreation, financial gain 
would be the result. This lesson is particu- 
larly necessary for us in the South, at this 
time, with its marvellous material develop- 
ment. We have attempted to keep up with 
its progress, but have not yet learned the 
secret of working intensively for a short 
time and stopping. To illustrate; in At- 
lanta, the average business man is in his 
office at seven-thirty and works until six- 
thirty or seven in the evening at least; 
crowding in every hour with its full quota 
of work; in the Northern cities, scarcely 
any one is in his office until nine o'clock 
and by four or five the offices are vacated. 
He works as intensively while he is at the 
office as does the alert Atlanta man, but he 
does not work as long; he has learned bet- 
ter how to take care of himself. I think 
enough has been said now to present my 
case; my plea is for a readjustment of our 
life and recognition of what the body re- 
quires, what its capabilities and possibilities 
are, and that we give the individual self a 
square deal, not expecting more work than 
God required of it to perform. I believe 
that the present rate of living is developing 
an increased number of cases of nephritis, 
arterio-sclerosis, and rheumatoid conditions; 
it is time that we called a halt. 



What? Where? When? 
And How?* 

Dr Albert J. Caldwell, Amarillo, Texas. 

In presenting this papar I do not desire 
to be considered sensational: neither do I 
wish to establish a dangerous precedent in 
the writing or in the presensation of papers; 
before this body, merely hoping to present 
this question in a manner calculated to 
make the Profession "sit up and take 
notice" of a prevalent condition in child- 
hood that has produced a greater number 
of Phenomena than probably any other 
thereto pertaining. 

The subject has been "threshed" thor- 
oughly. It has been presented in nearly all 
of its phases, forms and conditions' so to 
speak, not only by the wise men of the 
East who have smelled of the Moschus 
Moschiferous, who in their wisdom have 
set heavily on the subject, but by every 
Tyro, in the ranks, who has been at some 
time or other, seized with a burning desire 
to enlighten the world-Medical along these 

In discussing this subject, at this time, I 
would be recreant to the title selected 
should I fail to attempt to answer the inter- 
rogatories which form a part thereof. 

The first two, i. e. What? And Where? 
are best and can be more clearly answered 
and defined at one and the same time. 

The tissue termed Adenoid, or Adenoids, 
is a soft lymphoid mass lying in the vault 
and along the posterior wall of the naso- 
pharynx, and somewhat, though, to a 
lesser extent, in the Fossae of Rosenmuller, 
posterior to the Eustachian orifices. It is 
an overgrowth of normal glandular tissue 
designed to moisten this region, as well as 
assisting to moisten the inspired air. 

Here let me assert a universal law per- 
taining to cause and effect relative to the 
nose and threat : Nature intended that the 
normal nose and throat, with its cavities 
and its glands, should furnish approximate- 
ly a pint of secretion during the twenty- 
Four hours, for the purpose of moistening, 
warming and filtering the inspired air, 
thereby placing it in a proper and suitable 
condition for the receptivity of the lungs. 
Consequently a blocking of the naso- 
pharynx, not only lessens the amount of 
normal secretion, but changes the current 
of air from the nose to the mouth, thereby 
lessening, or preventing, the process de- 
signed by nature in preparing the air for 
the lun^s, as referred to above. 

This tissue, or Adenoids, becomes Path- 
ological on account of its size and the re- 

*Read before the Pan Handle District Medical 
Association, of Amarillo, Texas, January 9th and 
toth, 1908. 

suiting interference with nasal respiration, 
facial development and a proper aeration 
of the middle ear, through its proximity to 
the opening of the Kustacrfian tubes, it is 
prone to acute and chronic inflammation, 
and liable tb tubercular infection. 

This condition is peculiar to early child- 
hood life, although present in a large num- 
ber of cases of riper years. 

In a collection of four thousand (4.000) 
cases reported from a London Hospital, 
three thousand (3,000) were between the 
ages of three and fifteen years : two thous- 
and (2,000 ) were between the ages of three 
and ten years, while three thousand five 
hundred (3,500) were between the ajjes of 
three and twenty years. 

This record, together with the fact that 
there is evidence of a gradual increase in 
number up to puberty, is strongly presump- 
tive evidence that the pharyngeal tonsil 
undergoes a natural growth during child- 
hood and that it becomes liable to hyper- 
trophic changes as puberty approaches. 

I have examined infants under twelve 
months of age in whom the pharyngeal 
tonsil was scarcely palpable, but in the 
course of three years it had become so prom- 
inent as to demand operative interference. 
This fact warns us that although an infant 
may present but a mere trace of this tissue, 
our prognosis must be guarded as to later 
trouble, and any operation then undertaken 
must be especially thorough. 

It may happen that even after the most 
careful and thorough removal during infan- 
cy any Lymphoid tissue left in the Mu- 
ous Membrane may undergo Hyperplastic 
changes, and require attention later on. 
Especially when the naso-pharynx and 
Choauae are so diminutive that even a 
small mass of Adenoids may be sufficient 
to block the breathway. 

While bearing in mind that these figures 
only represent the ages at which the patients 
came under treatment, they may be taken 
as fairly indicative of the age periods 
when the Adenoids are largest and most 
troublesome. Their accentuation at puberty 
may be due in no small measure to the very 
frequent enlargement of the turbinals ; 
especially the inferior, which consisting 
largely of a species of erectile tissues, sym- 
pathetically share the special functional 
activity of that period. This, in turn, me- 
chanically facilitates the hypertrophic 
changes in the Adenoids themselves, and 
is partly responsible for their recognition. 

The youngest in this list was five months 
old ; while the oldest was forty-four years. 
Yet this does not represent extremes since 
Astier reports an infant of six weeks, and 
Solis Cohen a patient of seventy years. 

The figures, however, confirm what 



many writers have already asserted : That 
Adenoids are most frequently met with be- 
tween the ages of six and fifteen. For 
after puberty the nasal and pharyngeal cav- 
ities become relatively larger by sharing 
the facial development, the symptoms of 
respitory obstruction are cousequentls less 
likely to be found. But in spite of the 
natural tendency of Adenoids to disappear 
and the natural enlargement of the sur- 
rounding cavities, a very large number of 
patients who come for treatment are be- 
tween the ages of twenty and thirty ; a 
striking contradiction to the belief, if Ade- 
noids cause no trouble before puberty, they 
are not likely to do so afterwards. 

It is by no means a rare experience to 
find large Adenoids in adults in whom the 
naso-pharynx is exceptionally capacious ; 
but are the subject of recent middle ear 
suppuration or other troubles. 

Age, therefore, although it cannot be 
said to have a direct, or specific, casual 
relation to Adenoids, possesses coincidental 
association not entirely devoid of clinical 
and pathological significance. 

Searching the mass of literature on the 
subject and a careful observation and study 
of the cases that come to us day by day, 
there is only one rational conclusion at 
which to arrive, i. e. that of careful and 
thorough removal. Tentative treatment 
only retards or lessens the pathological pro- 
cess, allowing it to pursue its course of 
death, devastation and decay untrammelled. 

The finger nail, the forceps and the 
curette have been christened, "The trinity 
of removal." In my opinion, the finger 
nail is not to be considered, the forceps 
questionable, unless the tissue is in one 
mass, well defined and centrally located; 
while the curette is the most reliable means 
at our disposal. 

We will not usurp your time in discuss- 
ing the merits and demerits of the various 
ways of removal. All of them tend to 
serve the same purpose. 

"Remove the entire growth without in- 
jury," said one noted Laryngologist, and 
in my opinion, that fits the case entirely. 
There is not question as to the indications 
and the results to be obtained. 

This tissue is the bane of childhood, the 
Bete noir of the physician, and the regret 
of adult life. Its effects are far reaching, 
and as countless as the stars. The Ear, 
Eye, Nose, and Throat are made to suffer 
in their functions by reason of its existence. 
Manhood and womanhood alike suffer 
from its ravages, mentally and physically. 
A tired listless expression, and a vacant 
stare, in many instances, are evidences of 
its handy work : while our institutions of 
restraint are peopled with its victims. 

Thousands of tired little feet and hands 
sleeping on the hillside," 'neath the dew T - 
drops and the daisies," whose spirits have 
gone to join the "choir invisible" are results 
of its influence and neglect. The cares of 
motherhood are augmented and the trials 
of life increased by reason of its being, 
while thousands of cases are permitted to 
live out a miserable existence while our 
learned Profession are wasting the years 
indulging in hairsplitting, theoretical dis- 
cussions trying to devise ways and means 
of non-operable treatment. 

If I have caused you to think, and later 
to act, I will be amply repaid, and, in clos- 
ing, permit me to remind you, that from 
time immemorial, sacred History hath pro- 
claimed from the pinnacles of the Ages, 
"In as much as ye did it unto one of these 
little ones, ve did it unto me." 

Abseess of the Liver. 

W. A. Br.yan, A. M., M. D., Nashville, Term., 
Adjutant Professor of Surgery, Vandervilt Uni- 

It is of more worth to a man to study 
something as thoroughly as his time and 
opportunity permit and to give the results 
of his studies, though he may not have 
thoroughly mastered the subject, than for 
him to rehearse most accurately something 
that he and all his readers have mastered 
long ago. So here, Im aattempting to study 
the diagnosis particulary, of hepatic ab- 
scess, for I was forced to review the subject 
recently in my work, and as all must so do 
I feel far from satisfied with the result. 1 
am offering nothing new. 

Situated on the surgical side and in the 
surgical end of the abdomen, if we omit 
gynecology, confused with gall-bladder and 
gall-duct lesions, with lesions of the stom- 
ach and duodemum, the kidney, the panc- 
reas and the appendix,in the abdomen, and 
with those of the pleura, the diaphragm, 
the lung and the mediastinuu, as well as 
the pericardium on the left side above : in 
itself subject to a large number of patho- 
logical changes, and at the same time alter- 
ed widely by diseases whose chief patholo- 
gy lies elsewhere, the liver will for a long 
time continue to puzzle the most astute and 
pains-taking diagnostician, and cannot but 
remain forever an unknown and unmean- 
ing field to the examiner of slack methods. 
It lies in the center of the storm zone of 
the abdomen, subjected to so numerous in- 
ternal and external vicissitudes that the 
best we can do in diagnosis is often pitably 

The evidences of abscess of the liver are 
to be divided into local signs and symptons 
and general or constitutional evidences. 
Then, to be practical, we are to search for 


evidence determining whether one or two 
large pockets of pus are present, or numer- 
ous small foci : whether, in a word, the case 
is or is not susceptible of benefit from sur- 
gical treatment. ( )f however much interest 
the purely scientific side of a case may, be 
the real will alwaysremain 

on side of practicability. Then comes the 
differentiation of liver abscess from various 
other confusing local and general condi- 
tions. It is absurd for the surgeon to imag- 
ine that he is so exclusively a mechanic, 
that it is useless for him to eternally develop 
in every possible way his diagnostic acu- 
men. The surgeon has always to remember 
that diseases overlap each other in their 
symtomatology, an atypical medical case 
resembling some distinctly surgical affec- 
tion, and another to-day non-surgical, while 
to-morrow it is surgery alone that offers 
hope for a life. 

Local Evidences of Liver Abscess. 

It is stated authentically, and 1 am pre- 
pared to believe it, that there is no sign or 
sympton of hepatic abscess which may not 
be absent. I may add, conversely, that 
there is almost no sign or symptom which 
may not be present without abscess. At 
times there are both no valuable signs and 
no diagnostic symptons. For the physical 
signs to have any great value, the abscess 
must have reached considerable size and 
must be located at or near the surface of 
the liver, and all deep or small abscesses 
must remain problematical. 

The liver is enlarged. This enlargement 
is in the line of least resistance and if it 
occurs more frequently in the upward direc- 
tion it is because of the situation of the 
abscess. When at or near the upper sin- 
face, upwards is the direction of encroach- 
ment : when situated in the lower portion 
the increased dulness will be towards the 
epigastrium. I have operated on a case of 
solitary abscess of the liver in which the 
line of liver dulness was not elevated, but 
below it reached to the crest of the idium. 
The limitation of the area of increased 
dulness will depend on the contour of the 
sed liver. 

Tenderness, where present may be either 
circumscribed or general over all the liver 
that can be reached by pressure. 
This tenderness will vary so widely as to 
be often of no value ; besides tenderness 
may result from many causes, and the phy- 
sician is to judge always of the extent of 
tenderness present from the statements given 
him by the patient under examination. 
The individual factor, the personal equa- 
tion is to be determined as much as possi- 
ble in every case. 

Fluctuation is valuable, when present : 

yet it by no means is to be interpreted as 
signifying pus, whenever the sign is pres- 
ent. It means fluid, and that only ; the 
determination of the nature of that fluid 
must be decided by other evidences or go 
undecided. It is, furthermore, difficult, at 
least in my hands, to be sure when one 
gets real fluctuation. especially if indistinct, 
due to the presence of fluid, or semi-fluctu- 
ation occuriug both in certainjnormal tis- 
sues and in other pathological conditions. 
The best means 1 know for eliminating 
error is to have an assistant press with the 
inner edge of the hand on the surface ly- 
ing between the palpating hands of the 
examiner and thus more or less effectually 
interrupt the waves of the solid tissues 
without in the least altering those trans- 
mitted through underlying fluids. Absence 
of fluctuation is only negative evidence, 
whose chief value often is to mislead the 
diagnostician and cause him to allow the 
last opportunity for saving a life to escape 
before a conclusion is reached. Now and 
then perhaps fluctuation may be felt, and 
that more easily in the intercostal spaces. 
The wideuess of the spaces, the tissues 
lying between the skin-surface and the ab- 
scess cavity and the location of that cavity 
are factors influencing the feasibility of 
intercostal palpation. 

The friction sound resembling that of 
a pleuritis may be heard if the peritoneal 
surface has become inflamed. 

Edema over the surface of the right lobe, 
when other suspicious evidence is at hand, 
is very important. It is one valuable sign 
of a deep suppurative process. Circum- 
scribed edema and infiltration are evidences 
of a threatened rupture of the abscess at 
the point of their appearance. It by no 
means follows that if left alone the abscess 
would always rupture at that point. 

Aspiration would seem to be capable of 
giving us a certainty ; but even this, the 
surest means of all, at times fails to show 
pus when present in considerable quantity, 
to say nothing of minute abscesses. The 
The evidence from aspiration will be more 
satisfactory always, in case no pus is with- 
drawn, to examine the serum, blood, and 
small chunks of tissue that may be obtain- 
ed by the needle. Failure to find present 
pus depends on the following self-evident 
factors : First, the needle may not be long 
enough or deeply enough inserted to reach 
the pus cavity ; second, it may become 
blocked, owing to small caliber or to pieces 
of tissue engaging in its lumen, so that 
suction cannot draw pus through it, third, 
it may pass completely through the abscess 
cavity and collect only bloody serum from 
healthy tissues beyond ; this last may be 
avoided by gradually withdrawing the nee- 



die before cutting off its connection with 
the vacuum. Aspiration should by no 
means be done without permission to pro- 
ceed at once with the operation in case 
the findings are positive. This in spite of 
certain claims that aspiration is harmless. 
It cannot be harmless if the needle goes 
into a pus pocket and on its withdrawal has 
the bacteria wiped off not only through its 
track in the liver but in the peritoneum. 
This has happened and fatal peritonitis fol- 
lowed the use of the aspirating needle. 
Hemorrhage, too, has occasionally been 
known to follow aspiration and result in 
death. Sadly enough, this is claimed more 
likely to happen in livers free from than in 
those containing abscesses. May I repeat; no 
man should ever aspirate for pus without be- 
ing ready at once to proceed with a competent 
operation. Maitland insists that, if a fruit- 
less puncture is made and a second or third 
needs doing to reach the various regions of 
the liver, it is better to withdraw the needle 
completely from the liver eacli time and thus 
avoid a shift in the direction of the needle 
within the substance of the liver and render 
hemorrhage less likely to occur. Aspira- 
tion, if done with trocar and cannula, may 
help in differentiating between a hepatic and 
a deep mural abscess, if the abscess is 
hepatic the flow is influenced by respira- 
tion, if mural it is not. 

Muscular rigidity is valuable if present; 
its absence signifies nothing. 

Pain may be absent ; usually it is found, 
and varies from an uneasy ache or ful- 
ness and heaviness in the hepatic area to 
severe intensity. It has the usual peculiar- 
ities of pain from liver tissues, namely that 
it may be felt entrely in that region, or may 
be referred to the epigastrium or the scapu- 
la, the shoulder and the arm on the right 

When sufficient involvement of liver tis- 
sue happens visible enlargement of the skin 
veins or the appearace of a caput medusae 
may be expected. 

Generel Symplons. 

When we take into consideration the 
the statement of so high an authority 
as Kehr to the effect that Rouis' series of 
cases showed local pain, increased dulness, 
tumor and fever in only 8% of the cases, 
we can easily see how severely and how 
often the clinician is put to the test to gath- 
er from a given case sufficient symptons to 
present an unmistakable picture of hepatic 
abscess; and how frequently he cannot feel, 
as he would like, that his diagnosis is much 
more than a surmise; how often, in fact, 
with the best he can do, he is far at sea. 

Of much importance is the history of the 
individual under question. I do not mean 

the simple asking whether the patient has 
recently been in the tropics or whether he 
has suffered from a dysentery. Important 
though they be, they by no means comprise 
a complete list. Far from it. My reason 
for emphasizing is that 1 have so often seen 
physicians satisfy themselves with an anam- 
nesis embracing no more, and have like- 
wise been myself so many times satisfied to 
inquire thus shallowly, that I feel most us 
of us are worthy to be censured. In the 
light of recent investigations > showing how 
numerous amebic abscesses are, it is forgot- 
ten that there is a great variety of other 
causes and that we have no right to let them 
lie hidden in the shadow of tropical abscess. 
Enumerating, they should be inquired after 
as follows ; Alcoholism, malaria, influenza, 
yellow fever, foreign bodies, contusions, 
wounds, especially gunshot wounds, round 
worms, diseases of the bile ducts and the 
gall-bladder, echinococcus, coccidia, tuber- 
cle, gumma, typhoid fever, ulcer of the 
stomach or duodenum, inflammatory pro- 
cesses in and around the kidney ; infection, 
ulceration or malignancy anywhere in the 
region whose venous blood is carried by the 
portal vein, such for example, as appendici- 
tis or pus in the retro-rectal or superior pel- 
vi-rectal spaces ; emboli brought from any 
remote atrium, escaping the lungs and 
lodging in the capillaries of the liver, a 
phenomenon explained, most plausibly by 
narrowing of these vessels from parenchy- 
matous swelling of the liver tissue. Briefly, 
hepatic abscess is plainly and unmistakably 
subject to the laws for the causation of ab- 
scess in general, viz., that any local or consti- 
tutional agent reducing hepatic resistance 
favors abscess formation ; any natural oracci- 
tal means that cause a deposit of pyogenic 
bacteria in sufficient quantity in the liver 
substance acts as the exciting cause of ab- 
scess ; any infection or suppurative pro- 
cess in the body may by one of the meth- 
ods of spread of such infection result in 
invasion of the liver. When it is remem- 
bered that the liver is one of the chief 
agents in eliminating micro-organisms 
from the body, it is more readily under- 
stood how the amoeba stands by no means 
alone in the etiology of abscess. 

General sepsis or the classical chills, fever 
and sweats of pus-formation, is of great 
value when present. But the recurrence of 
this group, resulting from liver infection, 
is so frequently very similar to malaria that 
differentiation cannot be made outside the 
laboratory. Recently I saw a case of this 
kind. The patient was a man, 47 years 
old, healthy, stout, active. Has had noth- 
ing, so far as could be learned that has any 
bearing on his present condition. For 
several days he had severe chills, high fever, 



and profuse almost incredible sweats, after 
which his temperature would come to nor- 
mal. Chills recurred daily. Later on as 
many as three a day. Bowels constipated, 
tongue white and thick. Widal persistent- 

tive : examination for Plasmodium 
negative. Liver dulness distinctly up to 
nipple and 3 inches below margin of ribs ; 
fluctuation indistinct, and uncertain owing 
to fat. Spleen enlarged moderately. Leu- 
cocyte count L60.000, 70 percent, polymor- 
pho-nuclears. What was it ? The atten- 
dant leaned toward hepatic abscess. Hour- 
ly punctures were made for Plasmodium, 
which was found eight hours after chill, 
aestivo- autumnal variety. This time, three 
days later than last count, the leucocytes 
were 12,000. fen days later the size of the 
right lobe of the liver was well within 
bounds, but there was a dull area in the 
the left hypochondrium and displacenent of 
the apex-beat '.-inch above and to the 
right of the nipple. This time leucocytes 
were 22,000 with 90 percent, polymorpho- 
nuclears. The case remains under obser- 
vation, with his general condition gradu- 
ally improving; he has ceased to have 
chills and the average of his daily temper- 
ature is much lower. 

Loss of appetite and the consequent 
weakness, emaciation and anemia is the 
rule in liver abscess. Musser has wisely 
said that in case of an unexplainable revul- 
sion for food search for pus; for pus-absorp- 
tion always produces loss of appetite. 

ated urinalysis has a curious value, 
if the case can be watched through the 
inflammatory process to pus-formation. 
When the increased circulation of hype- 
remia occurs there follows a rise in the out- 
put of urea : when the process has contin- 
ued to pus-formation the out-put is dimin- 
ished and continues to diminish as more and 
more of the urea-producing cells are de- 
stroyed : that is, in hepatitis, particularly 
acute, urea is increased; in abscess it is 

cj tosis is favorable to diagnosis of 
and a differential count has valu- 
able information for the surgeon. But 
when we consider that the leucocyte count 
markedly, slightly or not at all in- 
iu liver abscess, and that many 
other conditions may be associated with 
t of enlarged liver we cannot rely 
on this as having more than a very imper- 
fecl diagn< istic \ alue. 

Jaundice may appear during the course 
of hepatic abscess, but is unusual andmore 
likely to prove a snare than an aid to the 
surgeon, sin..- il occurs also in other septic 

The duration oi hepatic abscess covers 
varying periods oi time. Eichhorst says : 

''The duration of liver abscess may extend 
over a few weeks, some months or several 
years (to 15), so that we must distinguish 
between acute, sub-acute and chronic liver 
abscess." Tropical abscess is slow and 
the constitutional symptoms are less mark- 
ed than in acute and subacute. 

Rupture of hepatic abscess occurs now 
and then. The direction of this rupture 
may be upwards, producing subdiaphrag- 
tic abscess, or into the pleura or lung, 
whence the pus is coughed up containing 
the tell-tale evidence of its origin. It may 
open onto the outer surface after adhesion 
has occurred between visceral and parietal 
peritoneum ; or into the general peritoneal 
cavity, rapidly developing peretonitis; or 
into a large vein to result in sudden death. 
It may rupture also either into alimentary 
or urinary tract ; the symptoms of each 
class are sufficient in most instances to 
avoid error. 

Rupture and escape of contents, if in a 
favorable direction may result in self-cure 
of the case. This is also accomplished by 
calcification and iuspissation. Any such 
outcome is so rarely seen that it is worth- 
less to consider it as a possibility. 

If the abscesses are small or very num- 
erous, the symptoms are little, if any, differ- 
ent from those of septico-pyemia. I saw 
a case recently of this kind. The patient 
had been alcoholic with a big liver. He 
developed septic symptoms following a 
self-inflicted knife-wonnd of the neck. 
Abscess of the liver was diagnosed and he 
was sent to me for operation. Aspiration 
was done and proved negative. Post-mor- 
tem showed numberless small abscesses 
throughout the abdominal and thoracic 

The favorite position of patients having 
liver abscess, if there is one, is supine with 
the right thigh flexed and the body bent 
toward the right (Kehr). 

The spleen is enlarged in hepatic abscess: 
it likewise has the same capacity to confuse 
that enlarged liver has. It so frequently is 
associated with enlargement of the liver in 
non-septic cases that its diagnostic value 
is small. 

When the lung is compressed or the pleu- 
ra is inflamed, dyspnoe and cough apperra. 

So the diagnosis of liver abscess, as oth- 
er hepatic lesions, is an uncertain quan/itv 
and we must continue to overlook them and 
mistake other lesions for them until some 
more definite or more tangible evidence can 
be brought into service. 

Spasmodic Croup in Children. 

By W. T. Grove, M. I)., Eureka, Kansas 

The subject of croup is one that interests 
all, but perhaps more especially the young 


practitioner. The doctor is usually called 
at 11 o'clock or perhaps somewhat later in 
the night, to hurriedly reach a very sick 
little patient. These attacks come on usu- 
ally in the early fall or winter, and the lat- 
ter days of spring time. The attacks gen- 
erally follow the night after a beautiful, 
sunshiny day, the child having contracted 
a cold during the day. In my experience, 
one of the greatest causes for such trouble 
following such nice, warm days, is the fact 
that inasmuch as the day was beautiful, 
children who are accustomed to staying in 
house, perhaps in many instances badly 
ventilated, are allowed by the mother to 
play in the yard or in the road, perhaps 
not thinking whether the child is prop- 
erly clad, even if the day be so nice. The 
mother is doubtless busy with her do- 
mestic duties, the child is allowed to 
become thoroughly chilled, and internal 
congestion results. They are proba- 
bly running and get sufficiently warm and 
along with it breathe through their mouths, 
thus taking air into the larynx which is 
cold, unwarmed and uninoistened by the 
turbinated bodies. 

Perhaps our patient may be a victim of 
adenoids and has enlarged tonsils, in fact 
the majority of them are, and you may 
have complications of earache, and so- 
called otitis media, which might result into 
a suppurative type. The trouble usually 
commences with a cold or so-called rhinitis, 
caused by the cold and mouth-breathing, 
the child playing on the cold, damp ground, 
thereby facilitating and intensifying the 
condition which is supposed to be harmless 
by the mother, owing to the beauty of the 
day, the glowing sun and apparent warm 
atmosphere. The child perhaps eats more 
heartily for supper, undoubtedly many things 
which do not agree with his digestive ap- 
partus. In lying down you have a blocked 
or congested condition of the nares, naso- 
pharynx and fauces. The trouble extends 
to the larynx. The little patient's laryngeal 
opening which is perhaps small becomes 
swollen. This in turn inflames the muscles 
of the vocal cords, thereby rendering them 
tense similar to that of other muscles in 
cases of trauma or inflammation, and they 
are merged into a so-called local spasm. 
When this happens respiration is embar- 
rassed, the child feels a sudden tendency 
to asphyxiation and commences to cough 
and try to relieve himself and perhaps he 
is hardly awake before he has aroused the 
mother with his rasping, violent, croupy 
cough. She at least becomes alarmed and 
sends for medical aid in post-haste. The 
old fashioned remedy used to be a prompt 
emetic and the one most usually used was 
tartar emetic, turpeth mineral, or ipecac, or 

the compound syrup of squills. These 
would generally relieve the condition fairly 
promptly, relax the patient, but at the same 
time depress them, producing nausea 
which is likely to be prolonged. 

Some fourteen years ago I was called to 
see a little patient (Dot B.) who had suf- 
fered the year previous from a true case of 
perhaps diptheritic croup. The ordinary 
emetic did seem to relieve this little patient. 
The headquarters being quite comfortable 
and the mother being very loving and kind, 
both to the child and to me, allowed me to 
go to bed. It being in the country quite a 
distance and the tendency of the croup to 
not yield to ordinary methods induced me 
to accept of the invitation to stay all night 
in order that I might relieve the little pati- 
ent at any future time during the night. It 
was at this time the thought struck me, if 
he bromides were good to relieve spasm of 
a general character, why would they not 
be good to relieve spasm of a local charac- 
ter, such as we find in an attack of spas- 
modic croup, in the vocal cords and laryn- 
geal muscles ? So I proceeded to give the 
little patient from one-half to one drachm 
doses of the elixier bromide of either potas- 
sium or sodium, whichever happened to be 
handy. This was ordered to be given every 
half hour until the patient became quiet 
and fell into any easy breathing sleep. I 
usually dilute the medicine about one to 
four to six in water. We usually put 
around the patient either hot bricks or hot 
water bottles, in order to bring about a nice 
little sweat of sufficient warmth to induce 
a mild state of diaphoresis to just the ex- 
tent to induce the perspiration to appear. 
This aids the bromides in relaxation and 
induces in perhaps one-half to one hour or 
one and a half hours a sweet, refreshing, 
unembarassed respiratory sleep. Every- 
body seems glad and our little patient 
sleeps with us. 

Since that time, rather than give the 
nauseating drugs, it has been my custom 
to rely almost wholly upon the bromides to 
control this condition, and it has been so 
successful in my hands that my patients 
always keep a stock of the same on hands, 
especially where there are any symptons of 
croup. This allows the doctor to get his 
usual office fee, saves a night visit, and 
also the mother of the anxiety as soon as 
she notices any symptons of croup appear- 
ing, and is usually readily administered. 
Iodized calcium has been greatly lauded 
and it has been my custom of late to use it 
in one grain doses every ten to fifteen min- 
utes in connection with the bromides, but 
whether it does any good or not I am una- 
ble to say . 

The manner of administering the bro- 



mides is as follows: — A baby several 
mouths old up to a year old I give one-half 
drachm doses of elixir sodium or potassium 
bromide every half hour in four times its 
volume of water, until the child is relaxed 
and quiet. Usually two to three does are 
sufficient. Subsequent doses need only to 
be given two or three or lour hours apart. 
Older children we increase the dose up to 
one, one and a half or two drachm doses as 

Along with my treatment, more especial- 
ly the day following, I order one or two 
warm baths to begiven, one in the morning 
and the other just before retiring, using a 
nful of magnesium sulphate to one 
pint of water. The object of this bath is 
to hasten elimination of the skin glands, 
thereby relieving the mucous membranes 
of their congestions. I usually give a phy- 
sic, most generally calomel perhaps about 
one -rain, and by morning this is sufficient 
to purge the bowels so as to work off the 
toxic materials from the bowels, liver and 
glandular system in general, together with 
its antiseptic effect upon the swallowing of 
exudate which is coughed up and snuffed 
back in the posterier nares and swallowed 
by such little patients, as is always the case 
in any respiratory trouble and by an ordi- 
nary cold, cold with croup or pneumonia, 
and by the child vomiting up any of the 
medicine we have accomplished what our 
forefathers tried to do. If the stomach 
seems to be nauseated I usually apply a 
mustard draught to the epigastrc region, 
which acts very nicely to allay same, to the 
extent of gentle redness. These 1 usually 
keep in my grip, prepared by any of the 
bouses, and in two or three minutes you 
get the effect. 

If any one doubts the efficiency of the 
effect of the magnesium sulphate bath I 
advise him to use the bath preparation when 
In- is feeling bad and knocked out. Take 
an ordinary sponge bath every night for 
three or four nights before retiring. Soap 
must never be used in this bath for the rea- 
son that it is acid in reaction and soap is 
alkaline in reaction and the magnesium 
sulphati the soa]. and reforms 

a very dirty, disa.^reea- 

I give in connection with this a little 
aconite, which always acts very nicely in 
all colds, using about two drops to the 
ounce combined with five or ten grains am- 
monium carbonate in syrup of tolu, one- 
half teaspoonful every half hour ; or in 
lieu of that 1 use veralruui the same dose 
with six to eight drops to the ounce. I 
not infrequently in fact, combine the aco- 
nite and veratum, using about one-half of 

each of the above preparation when com- 

Then it not infrequently happens that 
when a person is called to a croup case 
this plan of procedure will quiet it but you 
have a repetition of the same the night fol- 
lowing, and perhaps the next night follow- 
ing. In some cases this might possibly be 
an ordinary spasmodic croup, but where 
the conditions remain it generally develops 
into a true laryngeal diptheria or so-called 
pseudo-membraneous croup. Our little 
patient in such conditions does not feel so 
well the next day, he is knocked out as it 
were, and the second day he is knocked 
clear out. It is always well to inspect the 
fauces. In the former case you will find 
redness which is very nicely relieved by the 
application of ten grains of menthol in one 
ounce of liquid petrolatum, swabbing the 
fauces, pharynx, and extending down to 
the larynx with the application. Where 
you have the tyye that does not get well the 
first night and continues two or three days, 
if you will notice the breathing you will 
notice a peculiar labored respiration, be- 
coming more and more embarrassed and 
you have a peculiar cough, One way you 
can illustrate it is like a chicken when you 
catch him and he tries to squall and you 
catch him by the throat and choke him, he 
makes a peculiar sound which reminds me 
of a cough in a so-called membraneous 
croup, which cough is pathognomic of mem- 
braneous croup or diphtheritic croup. In 
all such cases the earlier you can inject 
anti-toxtine and in sufficient doses, the 
more happy you will be in a day or so. 
And when any such suspicious are aroused 
it is best to quarantine the little in one 
room, especially if you have other children 
in the family. It is not the purpose of this 
paper to take up the treatment of dipthe- 
ritic croup. I only mentioned this so as to 
put the practitioner on his guard, because 
it has happened a number of times with 
me where we supposed we had an ordinary 
case of croup, which resulted in a very 
short time in a well defined case of laryn- 
geal diptheria. 

Of course there are other measures that 
might be mentioned, but the object of this 
paper is to mention the conditions which 
bring about a croup, together with my 
treatment, which has been a source of great 
pleasure to me. I do not know that I have 
read of this any place, neither do I claim 
that it is original with me, but I tried it 
upon the analytical theory as above claim- 
ed, and I have never had reason to depart 
therefrom, as it has alwavs served me well. 


Cases of Head Injury with Operation. 

Read before Virginia Medical Society at Chase 
City by H. Stuart Maclean, M. D., Prof, of Pa- 
thology, Univ. Coll. of Medicine, Richmond, Va,. 
Chief Surgeon, Va.; R. & P. Co.; P. & P. Co.; R. 
& C. B. Cy. Co , Visiting Surgeon, Virginia 
Hospital, Richmond, Va 

Cases of head injury are of special in- 
terest because of (a) the attendant difficul- 
ties in differential diagnosis; (b) the slow 
development of sequellse in many instances; 
(c) the fact that the diagnosis is frequently 
dependent upon peripheral demonstrations 
far removed from the seat of the trouble, 
combined with a complex array of symp- 
toms referable to a variety of causes. 

Brain lesions may be considered under 
the heads of "Concussion," "Contusion" 
and ''Compression." 

Cerebral concussion has been the source 
of much study and many diversified opin- 
ions. It is characterized by an unconscious 
condition varying in severity — a condition 
which directs attention to a widespread in- 
volvement in the cerebral cortex, where are 
located the various conscious centres. It 
yet remains to reconcile such an involve- 
ment with the usual scarcity of post-mor- 
tem findings in many of these cases. The 
symptoms have been explained as due to 
the effect of a more or less violent vibra- 
tory motion of the brain. The experiments 
of Koch and Filchne have demonstrated 
that the symptons of concussion may be 
produeed by rapid slight blows as well as 
by a single violent blow, and this leads to 
the conclusion that the effect is one of de- 
rangenent in functionatiou rather than in- 
jury to or dissociation of the cells. 

Where so many different opinions seem 
to hold with reference to the actual condi- 
tions existing in concussion, it usually 
transpires that there are more than 
one etiological factor, and in one case 
reported below (Mrs. M. ) I met with a con- 
dition which I believe might be considered 
as offering a reasonable explanation for 
some cases of concussion. After opening 
the dura, a copious, rhythmical flow of 
clear, straw-colored fluid occured. The 
quantity Iprobably reached six drachms 
during the operation and continued for 
some time through the drainage. In this 
case there existed, among other injuries, a 
slight depression, and, as the patient was 
unconscious, trephine was done. No pres- 
sure from bone was found and there was 
absolutely no hemorrhage. The pulsation 
of the brain was noticeable, as was the in- 
termittent expulsion of the serous fluid 
from the wound. This edematous condi- 
tion must have been due to some local vaso- 
motor disturbance favoring transudation of 
scrum, with the consequent pressure effects. 

Had there been no other injuries requiring 
operation, I am inclined to believe the cere- 
bral effects would have passed off in the 
way they frequentlv do in concussion. 

Concussion may be defined as a psycho- 
logical condition or brain shock, analogous 
in a sense to the peripheral and central 
nervous symptoms following shock from 
fright or accidents of various descriptions. 
Essentially a true case of concussion car- 
ries with it no gross lesion. When there 
exists any tangible lesion, as punctuate 
hemorrhage, softening, or separation of the 
cortex from the white matter, it has passed 
into the class of contusions. 

Contusions of the brain may be very 
extensive without giving rise to decided 
symptons. In it we always have a greater 
or less amount of laceration of the brain 
substane, with the attendant capillary 
hemorrhage and the natural steps of exu- 
dation ; and effort at repair or regeneration 
in such cases may result in long continu- 
ance of the symptons and even serious 
permanent defects. The possibilities of 
serious effects are greater in contusion than 
in compression. 

It should always be borne in mind that 
in fracture of the skull with depression of 
bone, the symptoms may be due to lacera- 
tion of brain substance and not to pressure 
effects. This would explain why in some 
cases operation gives immediate relief and 
in others relief comes slowly if at all. 

Localization is not always possible in 
contusion of the brain with fracture 
of the skull, as the force producting 
the injury, when it has passed the skull 
and reached the brain, is transmitted in 
all directions. In this way, large areas of 
the brain may show damage ; as, for in- 
stance, extensive laceration with accom- 
panying hemorrhage, when a mixture of 
blood, serum and brain substance will flow 
from the wound in the form of a thick, 
grumous fluid. It is probable that the dif- 
ference in density of the gray and white 
matter of the brain predisposes to lacera- 
tion at the point of junction of the two in 
cases of violence, the vibratory waves last- 
ing longer in the one than in the other. 

Cases of compression constitute the lar- 
gest portion of brain injuries and usually 
preents a symtom-complex which admits of 
fairly accurate differential diagnosis, espec- 
ially when there is a history of head injury. 
Free blood in various stages of coagulation 
and fragments of bone constitute the for- 
eign substance responsible for the compres- 
sion. The capacity of the skull is fixed, 
as is the quantity of its brain contents, and 
this proportion can be varied only by re- 
duction in the amount of blood or with- 
drawal of the cerebro-spinal fluid. In trau- 



inatic compressions, the foreign substance 
encroaches upon the brain, which is con- 
gested and edematous I wet ; from the asso- 
ciated irritation : hence the pressure symp- 
toms appear more quickly than in the case 
of a slowly developing tumor or abscess, 
where the brain can in a measure accomo- 
date itself to the increasing pressure by 
constriction of the vessels and shifting or 
absorption of the cerebro-spinal fluid. 

Duringlthe present year I have had nine 
cases of head injury requiring operation on 
the brain. These cases have all been of 
considerable interest in presenting either 
new conditions or unusual complications, 
but, for the sake of brevity, only five will 
be described in detail. 

Six of the cases had external wounds, 
eight had fracture of the skull, seven had 
clots, extra or subdural. Five were oper- 
ated upon within a few hours after the in- 
jury, one was operated upon twenty-four 
hours after the injury, one two days after- 
wards and two four days after. Of the nine 
cases, eight made uneventful recoveries 
and, so far as they can be traced, are per- 
rectlv well now. 

The treatment has been to open the skull 
with a three-eigth inch trephine, enlarging 
the opening as recmired with a de Vilbiss 
forceps, which has entirely supplanted tre- 
phine in my hands. Openings measuring, 
roughly, threefourths by one and a half 
inches have been made quickly and smooth- 
lv with this very handy instrument. Drain- 
age is freely used — either small rubber 
tubing or tightly twisted stands of silkworm 
gut, packing the bone opening lightly with 
gauze. No foreign body has been used to 
replace or stimulate regeneration of bone 
in the closing of these wounds, the only 
procedure being to draw the peritosteum as 
far over the opening as possible, allowing 
it to fall in on the dura mater. It has hap- 
pened that the nine cases 1 have had this 
year have been young people, and my ex- 
perience has been that there is considerable 
regeneration of hone under these circum- 

I have not had much experience with the 
use of foreign bodies for replacement, but 
am theoretically prejudiced against their 
use and, should the occasion arise for fill- 
ing a large opening, 1 intend to do it by 
transplanting a piece of the outer table, 
with its periosteal covering, adjacent to the 

These cases and, in fact, all the brain 
cases I have had in the last few years — 
have impressed me with the remarkable 
tolerance of the organ to operative work 
and the comparative rarity of inspection. 
All these cases were freely drained, the 
drainage being removed in about thirty- 

six hours and the wound dressed in a rou- 
tine manner; yet in but one (the last re- 
ported) has tehre been a suspicion of in- 
fection. So strongly has this been impress- 
ed upon me that I am inclined to advise 
trephining in place of lumbar puncture 
in cases of cerebro-spinal mengitis when 
decompression is indicated. I would cer- 
tainly prefer a small trephine opening 
in meningitis cases where the symptoms 
pointed to a preponderance of the cerebral 

Case II — M. J.; age 25; colored. Lace- 
rated wound on back of head, with frac- 
ture of skull in upper portion of occipital 
bone one inch to right of the median line. 
The upper margin of the fracture was de- 
pressed one-fourth of an inch for a distance 
of three-fourths of an inch. Upon remov- 
ing the depressed . bone and incising the 
dura, about three teaspoonruls of brain sub- 
stance flowed from the wound. There was 
practically no hemorrhage and no clot. 
The case was drained with silkworm gut 
and left the hospital, perfectly well, in 
three weeks. 

Case V — A. I.; age 19; white. Was 
sent to me from Caroline County with the 
following history: He had been struck on 
the left side of the head by a falling limb 
while cutting lumber, receiving a consider- 
able bruise but no wound. Twenty-four 
hours later he developed a slow pulse with 
severe headache. I saw him two days later, 
when he had partial loss of motion of the 
right arm and leg but no facial paralysis. 
Operation the next day revealed a stellate 
fracture of the outer table with splintering 
of the inner table. The dura was lacerated 
and an oval clot, very firm in consistence, 
was removed with difficulty. Pushed direct- 
ly into the substance of the brain and im- 
bedded for a distance of about a half-inch, 
was a spicule of bone about five-eighths of 
an inch long and three. eighths of an inch 
in width at the base. The edge of this 
piece of bone was located only after a 
search inaugurated because the piece was 
missed from the inner table. This case was 
drained for two days and healed up prompt- 
ly, with complete recovery from all the 

Case Y I — Mrs. M.; age 22; white. In- 
jured by being thrown down by a street car 
and dragged under the fender for a consid- 
erable distance. She had the following in- 
juries: compound comminuted fracture of 
both bones of the left leg; lacerated wound 
of calf of right leg; compound Colles frac- 
ture of right wrist: extensive lacerations ot 
back of left hand; punctured wound of 
right elbow joint; several cuts on the face 
and three bail scalp wounds. 1'atient was 
unconscious when brought to the hospital, 


with a pulse of 68. She could not be 
roused, the response to peripheral stimula- 
tion was very sluggish and uncertain and 
the pupils were moderately contracted and 

While dressing the wounds it was discov- 
ered that there was a depressed facture at 
the bottom of the wound above the right 
temple, and, as the depression was one- 
fourth of an inch in depth, it was determin- 
ed to trephine while the other dressings 
were being done. A three-eighth inch but- 
ton of bone was removed and. upon incis- 
ing the dura mater, a quantity of clear, 
straw-colored fluid poured out, flowing with 
rhythmical interruptions corresponding to 
the pulsations of heart. There was no inter- 
cranial hemorrhage. The wound was closed 
except for a little gauze drainage in the 
bone opening, through which the serum 
continued to flow with surprising freedom. 

This woman resumed cotisciousness very 
slowly, but at the end of two weeks she 
has entirely regained her mental faculties 
and the sensation of her limbs. Her con- 
valescence was, or course delayed by her 
other injuries. I believe that, so far as 
the cerebral trouble was concerned, this 
woman simply had concussion and would 
have recovered from it without operation: 
certainly she had no apparent laceration or 
hemorrhage of the brain, and if her symp- 
toms as referable to the brain were the re- 
sult of concussion, then it is reasonable to 
assume that the extraordinary amount of 
serum found bore some causative relation 
to those symptyns. I believe the shock of 
the accident produced a vasomotor paraly- 
sis which favored the abnormal escape of 
serum and the symptoms resulted from the 
pressure incident thereto. 

Case VIII — J. p.; age 16; colored. This 
boy was thrown from a wagon, striking on 
the top his head. He seemed all right for 
twenty-four hours, except for headache and 
a pulse ranging from 60 to 70. Then he 
lost the power speech. No other facial symp- 
toms presented themselves except that at 
intervals he 'would have a momentary 
weakening of the muscles of the right side 
of the face and a deviation of the tongue 
slightly on the right side. This symptom 
was very transitory and I did not consider 
it sufficiently definite to determine the wis- 
dom or site for an operation. Seventy-two 
hours after the accident, he was taken sud- 
denly with violent convulsive seizures, 
which, as they relaxed, left partial paraly- 
sis of the right arm and leg. I had consid- 
ered the advisability of trephining over 
the speech centre on the left side prior to 
these seizures, but had been deterred by 
reason of the conflicting symptoms occur- 
ring in the face ; but upon development of 

the convulsions I made immediate prepara- 
tions and trephined on the left side about 
one inch above and one-half inch in front 
of the left ear. There was no pulsation of 
the dura upon exposing it, and upon open- 
ing it the brain presented and protuded. 
A grooved director was passed directly into 
the cortex. At a depth of one-half inch a 
quantity of grumous, clotted blood rolled 
out alongside the instrument. Altogether 
about 1 drachm was expelled. This clot be- 
ing lound just above the fissure of Sylvius. 
I felt sure there was more trouble higher up, 
so I enlarged the opening in the bone up 
about three-fourths of an inch toward the 
median line, when I found a transverse 
fracture of the skull with a separation of 
about one-sixteenth of an inch, and both a 
sub-dural and extra-dural clot. From the 
amount of separation of the edges of bone 
I estimated that the fracture must have 
been several inches in length, but, of course, 
did not endeavor to trace its extent. The 
extra-dural clot was a small one about one 
inch in diameter and one-fourth of an inch 
thick, but the sub-dural clot was a large 
one, about two inches in diameter and 
three-fourths of an inch in thickness. This 
clot was gradually wiped out, put in doing 
so profuse hemorrhage started from beneath 
the posterior margin of the bone at the point 
of fracture, which could be only temporari- 
ly controlled by packing, Believing that 
the hemorrhage was coming from the pos- 
terior branch of the middle meningeal arte- 
ry' which had probably been ruptured by 
the fracture and thus produced the clots, 
and not wishing to remove more bone in 
order to get at and tie the vessel, I stripped 
the dura free from beneath the posterior 
portion of the bone opening and grasped it 
firmly in a long-jawed artery forceps, hop- 
ing to thus catch the ascending artery and 
check the hemorrhage. This expedient was 
successful and the further steps of the oper- 
ation were completed, leaving the hemos- 
tatic in situ. The wound was well drained 
and dressings applied, leaving the handle 
of the clamp extending from the dressings 
to facilitate its early removal, which was 
done within twenty-four hours. Within 
fourteen hours the boy had regained con- 
sciousness and sensation and could an- 
swer questions in monosyllables, and in a 
little over'two weeks was up and walking 
about, the wound having healed promptly. 
This operation was performed about two 
months ago, and a few days ago I saw the 
boy. when he seemed perfectly well. As a 
large area of bone was removed, he has 
a space about an inch in diameter where 
the brain pulsation can be noticed, but this 
area has reduced almost one-half since he 
jeft the hospital. 



Case IX— R. B.; age 20. colored. This 
man went to sleep on the side of the R. & 
P. track, with his head resting on the rail, 
and it was struck by a car and rolled over 
by the pilot or wheel. Unfortunately, he 
had elected to put his head right over the 
plate used to bolt the rails together, and 
he had three deeply depressed fractures on 
the right side of his head, one about one- 
half inches further back and on a line with 
the first two. 

These fractures were deeply depressed or 
punched in, in the most posterior one the 
outer table being forced in past the normal 
level of the inner, and all three badly 
ground full of grease and grit. He also 
had a longitudinal fracture on the top of 
the head, about three inches in length, 
extending through the outer table, with 
much of the outer table gouged out, but 
without depression. I addition to the but- 
tons of bone, over thirty pieces were remov- 
ed from the fractures on the right side and 
the wounds well drained. 

For three days the patient lay in a stupor, 
with pulse ranging from 70 to 80, pupils 
reacting moderately and slight response to 
peripheral stimulation, with occasional 
spells of violent efforts to get out of bed. 
On the fourth day he showed signs of re- 
turning consciousness and began to speak 
in mi niosyllahles, and by the end of a week 
could say a few words, ask for things he 
needed and gave every evidence of recov- 
ing. On the ninth day his temperature 
suddenly shot up to 104°, pulse ran to 160 
and then became too feeble and rapid to 
detect, respirations between 50 and .55, and 
he lapsed into a profound stupor. The 
wounds were dressed when this condition 
set in, but they were clean and practically 
healed, except the one on top of the head, 
which was discharging a little pus from a 
pocket under the scalp. He died within 
eight hours. 

I believe death was due to some form of 
acute cerebritis or, possibly, an abscess at 
the base of the brain. 

Contribution to Local Anesthesia, i 

By I.. S. Oppenheimer, M. I)., President Associa- 
tion of Seaboard Air Line Surgeons, Tampa, Fla. 

A great many new experiments and in- 
vestigations are now being made in gener- 
al and local anesthesia. At no time for 
many years past has been manifested so 
strong a desire to improve upon the present 
crude methods. As surgery increases and 
the tyro "rushes in where angels fear to 
tread'' anesthetics become a dangerous 
blessing, and mortalities multiply. 

[■Read before the Hillsboro Co. .Med. Soc. Fan'y 
7th, [908. 

Investigations are going on with rectal 
anesthesia, heating and vaporizing the 
anesthetic, spinal anesthesia, nitrous oxide, 
ether and oxygen, bromide of ethyl, hyos- 
cine and morphine injections, and the 
numerous local anesthesias, with solutions 
of varying strengths of cocaine, eucain, 
magnesium sulphate, holo-caine, alypin 
and others, theSchleich infiltration method, 
the blocking of nerve trunks, etc. The 
multitude of these indicate our imperfec- 

This article intends merely to direct 
attention to cocaine local anesthesia with 
some restrictions and suggestions. This 
drug still offers the greatest advantage, but 
not in the solutions or manner commonly 
resorted to. A solution in plain sterile water, 
always freshly prepared, of 1-1,000 or 1-500, 
infiltrated thoroughly and liberally into the 
tissues to be disturbed gives ideal 
anesthesia in the vast majority of cases 
where local anesthesia is practicable. 
The quantity for various operations varies 
from 10 to 200 minims. These are 1-10 
of 1 per cent, and 1-5 of 1 per cent, 
solutions respectively, which are the 
strengths I customarilly use. I have never 
noticed any untoward effects follow- 
ing the use of these solutions. It should 
be remarked here for anesthetizing mucu- 
ous surfaces this is too weak. But the con- 
ventional 4 percent, solution when applied 
to throat or nose sometimes gives rise to 
alarming symptoms, and, occasionally has 
resulted fatally. For nose and throat work 
in children eucain or alypin are preferable. 
I do not give a general anesthetic for most 
adenoid or tonsil operations. Several fatali- 
ties have followed its application in simple 
adenoid work, and I am afraid of it. 

Naturally many physicians fail to get 
perfect local anesthesia with the weaker 
solutions. This is due to their faulty tech- 
nic — not to the anesthetic. I have observ- 
ed these failures repeatedly in the hands of 
some our best surgeons. As much skill 
may be required in this as in the general 
anesthesia, but the comparative dangers of 
the two are so much in favor of the local 
method as to be incalculable. 

I began using a 1 percent, solution for 
minor operations years ago. For the past 
five years I have used a 1-500 solution for 
many major operations including amputa- 
tions up to the middle third for the extrem- 
ities, fistulae, hemorrhoids, inguinal aden- 
itis, suprapubic cystotomy, appendectomy, 
herniotomy, radical hydrocele and varico- 
cele, circumcisions in adults and children, 
preceded in the latter by a few whiffs of 
chloroform and using a 1-1,000 solution. 

The subject is too extensive to enter into 
thoroughly in a paper of this kind, but I 


mav be pardoned for touching upon a few 
of the striking obstacles and a brief allu- 
sion to the technic. In amputations it is 
necessary to infiltrate and block off the 
nerve trunks just above the line of section 
by liberal deep injections with a long nee- 
dle. In fistulas, the two important factors 
are divulsion of the spincters and curret- 
tage. This anesthesia requires a solution 
not weaker than )'z of 1 percent. The 
technic consists in making thorough infil- 
tration of the skin area around the anus, 
then with a director or probe in the fistula 
inject around the entire tract or tracts, then 
inject around the sphincter area deeply. 
The divulsion requires but little more force 
than when under a general anesthetic, 
which as all of you know demands the 
most profound anesthesia known in sur- 

In smaller hemorrhoids that do not cover 
too large an area or too high up, the clamp 
and cautery are practically painless after 
the injections, which are made as in fis- 

In appendectomies when the peritoneum 
is reached, it is often found necessary to 
resort to general anesthesia, especially if 
there be much acute inflammation and 
adhesions. For pus cases the local 
anesthetic is all that is necessary. For the 
removal of tuberculosis or other glands or 
curettage of buboes the injections are made 
under and around the glands after the skin 
has been incised, and are followed up as 
the operation procedes. In herniotomy 
many operators fail with the local anes- 
thetic. The principal reason for this lies 
in their failure to specially anesthetize the 
nerve sheaths as they are reached in the 

This article makes no claim to being 
novel nor original, its only aim is to call 
attention to some points in this field that 
are either not generally known or are not 
made proper use of in every day practice, 
and the vital importance of the subject 
certainly demands the best endeavor of 
every conscientious surgeon. 

Cinical Gonorrhoea. 

By Thomas W. Murrell, M. D., Lecturer on Syph- 
ilis and Dermatology, Supt. of Genito-Urinary 
Dispensary, University College of Medicine, 
Richmond, Va. Consulting Dermotologist to 
Virginia Hospital and Methodist Orphanage, 
Richmond, Va. 

The above title has been chosen for this 
paper because to my mind there are two dis- 
stinct diseases, — the gonorrhoea of the text- 
books and the gonorrhoea calling at the 
physician's office. This is, of course, not 
a difference in disease but a difference of 
view-point and in no other disease does 
there seem to be such a lack of harmony; 

between the war-office and the army, be- 
tween the laboratory and the doctor. 

The medical world is a world of enthu- 
siasts. Enthusiasts are extremists and 
extremists wear blind-bridles. So it is 
that we have two types, the doctor being 
so engrossed in scientific research that he 
becomes dazzled by a scientific ideal or 
disgusted by the sane scientific claims, he 
falls back on empircism in either case at 
the expense of his patients. 

Due to this. we have violent champions 
of every new idea, these same champions 
have a new idea every time they read a 
clever article on the subject. The much 
vaunted specific of to-day is relegated to 
the garbage heap of to-morrow and what 
once held down the gonococcus can no 
longer hold such a man's good opinion. 

Because of the horrible results of two 
little science and the gloomy forebodings 
of two much science the question of the 
curability of gonorrhoea is a pertinent one. 
On one hand we have the convert of the 
German or Austrian school. His mind is 
full of the findings of those men whose 
practice is limited to the microscope and a 
dead body. He thinks of the mighty genius 
of Finger and this shadow falling athwart 
his treatment, he goes on his way with 
little confidence regarding himself as one 
who pallites but never cures. 

His friend, usually of the pre-aseptic 
era, lives in the past. He is an enthusiast 
over certain set prescriptions and considers 
all his cases cured. He laughs at the viru- 
lency of the morning-drop and gently 
pooh-poohs the microscope; lovable and 
much-beloved, a comforting optimist, he 
goes his way, literally uncorking vials of 
wrath on his unfortunate patients. 

Is there no middle ground to these two, 
for all knew them, cannot we combine the 
faith of one with the science of the other ; 
in other words, is gonorrhea curable? 

In answer to this question we should ask 
do you work for a scientific ideal or do 
you work for results? Personally, I cannot 
say whether or not I have eradicated all 
gonococci from the cases I have pronounc- 
ed cured, but I have treated cases in which 
an expert microscopist could find no gono- 
cocci in seminal discharge, strippings from 
the prostrate or by the inducing of an artifi- 
cial inflammation. These men have married, 
having no further trouble themselves, their 
wives remaining healthy and bearing chil- 

Even if Finger were right, what differ- 
ence does it make to me if gonococci are 
present which do no harm ? This I know is 
dangerous doctrine and rank bacteriologi- 
cal heresy, but in these cases, one of two 
things must have necessarily occurred; all 


nococci were killed or those that accurate way to study such a subject is to 

remained were rendered harmless. learn the histories of mature men and find 

I have no idea and cannot say which out what actually has happened, rather 

end of the ultimatum is the correct one, but than to attempt to estimate, on the basis of 

1 do know that any treatment that reforms a brief portion of the history of a few 

and transforms the gonoecus into a quiet individuals, just what will happen to all 

and peaceble citizen, does as much good as the rest of mankind, 
one which consigns him to a microbic hell. Krb found that of about 2,000 of his male 

The great Finger and the "gloomy Noe- patients representing all circles, but chiefly 

gerrath" with their disciples in their of the middle classes, whose sexual history 

extremity possessed one great virtue, name- was carefully investigated, just 48,5 per 

lv, they did no harm. cent, of all had gonorrhoea, while 45 per 

Every medical fad, as a rule, numbers cent, had neither gonorrhoea or syphilis. It 

its victims among its victories, but the must be admitted that a proportion of 45 

preaching of the gospel of the all-pervad- percent, of men free from venereal infec- 

ing gonococcus did good in every way tion cannot be a cause of great rejoicing, 

except in one. The wholesome respect for yet it is a decided improvement over the 

: icoccus is not misplaced and if a doubtful 5 to 20 per cent, of clean histories 

man can be kept from vice by terror, the grudgingly admitted by other statisttcians. 

results physically are the same as if restrain- Furthermore we are accustomed to believe 

ed by purest morality. that our American youths are not so prone 

But the -rea; cause of healing moves in to venereal infection as are the Teutonic 

no such garl). Truth must ever be its students, soldiers and officers — a belief that 

watch-word, plain and unvarnished truth, is probably well founded, 
and we are now seeing that while these As to the influence of this unclean 485. 

men were honest in what they taught, they per cent, of all male patients on the health 

in the bright light of science saw dark of their wives which has been so gloomily 

shadows with the substance and thought portrayed by many gynecologists, the expe- 

them one. rience of practioners who are familiar with 

In the American Medical Journal of entire family careers rather than with the 

July 6th or 7th there was an extract of selected material of the specialists seem 

Erb's report published in Munich in 1906 not to be so extremely bad. Among the 

which I will quote at some length : wives of 400 of Erb's patients who confess 

"It seems to have been gladly accepted to having had gonorrhoea some time previ- 
that at least 80 per cent, if not 99 percent, ous to marriage, 375 (93.75 per cent.) had 
of all men have suffered from gonorrhoea never suffered from pelvic infection that 
at least once; perhaps because such a con- could possibly have been of gonorrheal 
elusion permits the man who has been origin and but '17 (4.25 per cent. ) had had 
infected to look on himself as quite as good what probably were gounorrheal infectious. 
as his fellows, while he who has escaped As to the influence of ante-nuptial gouorr- 
the disease can boast himself as remarka- hcea on fertility, among the 370 couples of 
bly virtuous — or fortunate. Likewise the this class 68 per cent, had two or more 
claims of Xoeggerath and others as to children, 25 per cent, had four or more 
the prevalence of female suffering from children and but 12 per cent, were child- 
masculine unehasity has been well received less, and in most of these cases some reason 
by the pessimistic majority. A vigorous other than gonorrhoea was evident." 
shove of the pendulum in the opposite These observations are of special import 
direction has been delivered recently by in that they are clinical rather than patho- 
* Krl> first shows by what unwar- logical and even if the author is carried 
rained juggling of statistics many of the away by his own deductions, the wish 
widely-quoted results have been obtained, being father to the thought, yet allowing 
For example, one investigator found that for some exaggeration, the report is a tre- 
in one year twenty-five per cent, of all the menduous lever in opening eyes that Finger 
students in the Berlin students' sick benefit and Noeggerath have sealed. 

e venereally infected and promptly After all, the virulent "morning-drop" is 
deduced that every Berlin student is infect- but a medium and its virulency is due to 
ed once in four years. By similar mathe- its virulent contents. As an entity, and 
matical calculations another observer has especially so in old cases, the morning- 
determined that every man who marries at drop is more an indication of stricture than 
thirty has passed through two attacks of of gonorrhoea and a drop of serum, unless 
gonorrhoea — no more, no less! Iudividu- it contains infectious agents is no more 
ality enters not into the calculations of harmful than a drop of water. 

atisticians. Calculations on futuri- A urethra that is NORMAL will resent 

ties are purely gratuitous and the only the host of drugs used in local treatment 



and will speedily become inflamed. Then technique. I am not a musician, so I can- 
why does the doctor expect the diseased not verify his statement but had he applied 
urethra to act in a different manner. it to the treatment of gonorrhoea, it would 

What kills gonococci, kills epithelium have been a classic. The fact of the mat- 
and physicians seem to expect as soon as ter is that every method had its virtues and 
the last gonococcus yields up the ghost its faults. Every case presents different 
that the urethra in one bound will gain its features and different methods must be 
normal state. tried to attain success. 

Mauv fields in Virginia, to-day, are The hygeinic side of the treatment of 
scarred by the effects of battle and the gonorrhoea is a most important one and 
hunter in the thicket comes on burned tim- yet so easily over-rated, it may be carried 
bers of lordly mansions. The farmer too far. Since it is so very hard to induce 
ploughs up bullets and cannon balls but patients to do the things necessary, I omit 
the war is over, these fifty years. The a multitude of instructions and insist on 
country is well of war, but the scars re- only two things, a strict avoidance of Venus 
main. and Bacchus. This is so important that I 

It would be as sensible to send out artil- refuse to treat a patient who will not obey 
lery and bombard these same thickets as for otherwise your treatment may be use- 
to give gonococcidal treatment where no less and your reputation suffer. Nearly 
gonocccci can be found. This means all articles on the subject use the old catch 
reliance on exact clinical science which phrase "Avoid stimulating foods" whatever 
expressed in a word, means the microscope, that means. We may regulate the diet for 

It is amusing to talk to the partisan of the specific purpose of modifying the acidity 
any accepted method of treatment ; he or alkalinity of the urine, but I must con- 
seems to feel it his duty to blind himself to fess that I have never seen diet make much 

his failures and praise with a loud voice 
its successes ; — of other methods he can 
say but little that is good. The worst of 
it is or the best of it is that he can prove 

if any difference when the bowels were 
kept regulated. 

Stopping the use of tobacco in one habit- 
uated to its use> is one of simple folly. It 

his successes along that line. It is equally will do more to wreck the nervous control 

true that the partisan of the other methods than excessive use by the same person, and 

can do the same. tobacco can only be condemned as a ner- 

Why is this so? Why can one man do vous irritant. The less the pledge, the safer 

good with what is but a feeble aid to an- the pledge, 
other. The virtues and faults of the different 

The great composer, Litz, was asked the methods and drugs used in the treatment 

three requirements in a pianist, he replied : of gonorrhoea may be tabulated in the fol- 

"Lirst, technique, second, technique, third, lowing manner : 

Virtues. Faults. 

t Lessens Discharge, Chordee, Ar- Nou-gonococcidal, upsets di- 


-j dor Urinse. Disenfects and changes gestion, drug eruptions, 
(.reaction of urine. 


J Used by patient, used frequently Limited to anterior urethra. 

{ gonococcidal, astringent. 

More or less painful. 


I Reaches all urethra, gonococci- Used only by doctor. Trou- 

i dal, astringent. blesome, painful. 

In the same way we may classify a few of the drugs used locally : 

Virtues. Faults. 

) Strongly gonococcidal, valuable Very irritatiug in general Ure- 
'( in posterior urethra as instillation, thritis. Should be used only by 

\ Gonococcidal. Can be used in 
I general Urethritis. Irritating. 




I Gonococcidal. Non-irritating so Almost inert on tissue covered 
I can be used anywhere. with muco-pus. Expensive. 


Gonococcidal. Non-irritating. 

Dirty. Expensive. 

Potassium I Oxidizer, 
Pbrmanganate 1 Astringent. 

Feebly gonococcidal. Irritat- 



This could be carried out so as to include 
all drugs used but it suffices to show how 
futile it is to rely on any method for all 

I believe that a great deal of the harm 
and uon -success of the treatments of gon- 
orrhcea is due to that ancient and honora- 
ble fraud-anterior urethritis. Scientists 
give out a dictum with a mental reservation; 
th eral practitioner has no reservations, 

so with anterior urethritis. Of course, log- 
ical!) , there is bound to be at some time an 
anterior urethritis, but I do not believe that 
one case in a hundred could be justly 
so-called, ten days after infection has be- 
come manifest. Xo more chimerical idea 
can be well imagined than such a gross 
macroscopic body as the COMPRESSOR 
URETHRAE muscle can stop by contrac- 
tion the upward course of such a minutely 
microscopic thing as a gonococcus. We 
might as well expect a flea to be stopped by 
a picket fence. Because of the difference of 
the epithelium of the part one being squam- 
ous and the other columnar, the anterior 
urethal cells (squamous) readily answer to 
treatment, recovering in time without treat- 
ment and the gonococci flee to the fast- 
nesses of the crypts and folliciles of the 
r urethra as its final strongholds. 

So we have two conditions present and 
I believe that he who treats gonorrhoea by 
keeping the medicamet from going back of 
the bulbous urethra does so in the face of 
facts and at the expense of the patient. I 
have tried it, not once, but many times and 
after repeated re-infectious, have given it 
up in disgust as a simple theory. No sane 
man would attempt to treat a sinus of the 
rectum by washing out its lower end; then 
why treat this sinus so? For it is a sinus 
suppurating from end to end, and could we 
treat the disease with but the idea of eradi- 
cation in view, splitting the uretha from 
end to end and packing would be sound 
surgical sense. 

"Doctor, when will I be well?" How 
tired we get of the question, but then the 
patient is tired too and it behooves us to 
heed his cry. Can he be well, as long as 
he has a morning-drop ? Yes. As long as 
there are shreds in the urine? Yes. As 
long as there is congestion and pain in the 
posterior urethra ? Yes. As long as by any 
test known to man you can find a gono- 
cocci ? No; emphatically, No, and this is 
all that be called, prima-faciae evidence of 
stence oi the disease. 

In conclusion, I will say that I have 
written these things in no iconoclastic spirit 
or with the thought of attracting attention 
by differing with accepted theories, but as 
an endeavor to discover that country in 

which clinical facts and laboratory findings 
work hand in hand. 

"The Menopause." 

By Albert D. Parrott, M. D., Kinston, N. C, 

The "change of life," climateric, or me- 
nopause is the period when the function of 
menstruation, and usually also that of 
ovulation ceases. This is indeed a trying 
and important epoch of woman's existence. 
It is the autumn of life, with its chilly, 
blustering and turbulent winds. The bal- 
my spring and summer zephyrs no longer 
lend their gladdening and enchanting in- 
spiration. No longer does the peach, the 
fig, and the undulating grain fields bask 
in the warmth of the joyous summer sun. 
The harvest time is over. The mellow 
grain is now garnered in its sheath. And 
clustering around all this are the hallowed 
and sacred memories of a glorious and 
faithful past. 

It is the popular opinion that the earlier 
the menstruation commences, the earlier it 
will stop. This is a fallacy. The rule is 
that the earlier the menstruation begins the 
longer it lasts, that is the active sexual life 
which is measured by the menstrual life 
lasts at both ends, begins earlier, and per- 
sists later. Fragile illdeveloped women 
who menstruate quite late late, and whose 
sexual capacity is not vigorous, who have 
if married, few children and who if un- 
married, grow old prematurely seem to 
illustrate this fact. There are two very 
powerful factors — operating at this particu- 
lar juncture which confuse, alter, and 
reverse phenomena which almost invaria- 
bly accompany the cessation of this func- 
tion. It is generally concluded by the laity 
that this Mennorrhagia, is something triv- 
ial, a necessary adjuvant or an accompani- 
ment, signifying nothing, and that time 
the eternal effacer of all things will effect a 
cure. It is not enough to say when a wom- 
an is flowing profusely at the age, for in- 
stance, of forty-five to fifty that it is the 
"change of life," and that it is of no mo- 
ment, when she gets through the ''''change 
of life" it will stop and absolutely nothing 
be done to hinder it. If we stop to think 
on the other hand, it is just this copious or 
excessive flow that should interest, and ex- 
cite our suspicion, and of course the in- 
dividual should have our attention and 
treatment, as the case may demand. By 
our careful and painstaking efforts we may 
at this extremely unpleasant epoch, 
make her more comfortable, and allay 
much suffering and fear. 

If for no other reason than the great and 
increasing frequency with which malignant 
degeneration and other tumors make their 



appearance, especially during the decade deal to lessen the morbidity and render the 
from forty to fifty, taken singly, make it return to normal less precarious. 

quite imperative to investigate these cases 
with reference to their cause. I daresay 
if all cases where irregularities, and un- 
natural menstruation appeared were seen 
early, and carefully examined by the phy- 
sician, or were referred for diagnosis to a 
skilled Gyncologist, the very large and in- 
creasing mortality from carcinoma and 
other malignant neoplasms would be ma- 
terially lessened. Unquestionably if these 
cases were seen earlier, diagnosis made, and 
the proper medical and 

I dangers dared; I hindrance scorned; 

I omens did defy, 
Whatever menaced, harassed, warned, 

I passed impetuous by. 

Some Suggestions on Three Essential 

Points in the Treatment of 

Typhoid Fever. 

By Herman Hawkins, M. D., Jackson, Tenn. 
Medical literature indicates a universal 
agreement upon general principles in the 
rgical treatment treatment of Typhoid Fever but a great 
instituted, that the records of complete difference in practical application, 
restorative of health, and eradication of dis- It is evident from the variations in type 
ease, following operation for carcinoma and tendency to complications of this mal- 
would show an immense improvement over ady, an exhaustive analysis of the treat- 
the present compilations. I wish to reiter- ment would require a long paper for its 
ate that these should be looked upon with presentation; but the man who can control 
suspicion, and studied with a great deal of fever without harm to his patient, knows 
care and caution . A complete examination how best to nourish him, appreciates the val- 
should be urged in every case. ueof elimination and obtains it without det- 

The second factor that is of importance ri ment to the vitality, is in possession of the 
at the menopause is the nervous condition of three leading factors in the successful treat- 
the patient. There are extremely few women ment of this disease. In comparison the 
who do not suffer, and show well-defined rest is of minor inportance, tho not to be 
reflex and nervous phenomena in these neglected. 

waning years which constitute the so-called I do not deny the possibility of Typhoid 
"change of life." These phenomena of Fever beginning with a chill and high fever, 
course vary very greatly indeed, both in but such an onset is atypical, indicating 
extent and severity. In some individuals almost certainly some complication. It is 
they are exceedingly well-marked, and an ordinary experience to be called to a 
very distressing. For a great many it may case, with a previous history of general ill- 
be only a slight deviation from the normal, feeling, headache, coated tongue, loose 
or retrograde vitalit} — and thus often des- bowels, indigestion and some fever, sud- 
ignated ^nervousness." This may be and deuly reaching 103 or 104° F. and see the 
indeed often is the mere starting point for intensity of the symptoms alleviated by a 
grave future trouble, beginning slowly and thorough cleansing of the intestinal canal, 
quitely, suddenly bursting forth and over- leaving the tide like rise and fall of tem- 
whelming everything. Various functional perature progressively higher each day, so 
disturbances are quite common accompani- characteristic of Typhoid Fever. Again, 
ments of this period of life especially those it is not unusual to see the symptoms of the 
relating to circulation. The familiar "hot first week masked by acute malarial mani- 
flashes," and the peculiar moistening of the testations, which will yield to quinine, a 
entire body with perspiration, the irregu- plain case of Typhoid remaining. In cou- 
larities of the hearts action, strange long- ditions such as these with the diagnosis 
ings, nervous forebodings, and apparent still uncertain the cautious use of antipy- 
hypochondriacal conjectures, illustrate this retic drugs may be permitted, but their 
fact only too well. The methods and indi- administration should be strictly limited, 
cations for treatment employed will vary of for 1 would strongly empasize the general 
course with the predominating symptoms, rule "that drugs to control temperature 
Where there is faultv circulation as evinc- have no place in the treatment of Typhoid 
ed by headaches, "flushings, palpitation, Fever." This brings us to the conclusion, 
coldness and lividity of extremities, the that in the application of water we find the 

method of depletion by means of the glyce- 
rine tampon will be of unquestionable effi- 

safest effectual means for controlling the 
fever, therefore a brief mention of some of 

The tranquillizing of the nervous the ways of using it for this purpose should 
system by sedatives, the regulation of the be made. Like every therapeutic measure 
mode of life, combating mental depression, it must be adapted to the requirements of 
which is usually present by employment of the case and condition of the patient. The 

appropriate exercises, and out-of-door-life, 
all of these if carefully, faithfully, and 

Brandt bath is minutely described and 
ardentlv advocated in standard text books, 

intelligently persisted in will do a great but fortunately it is not practicable in 


general practice, For as a routine measure 
it is capable of doing great damage. The 
wet pack kept cold by ice rubbed over it 
Followed by brisk friction is a modified 
tion of the principal after resorted 
to successfully, but sponging with cold 
water is the usual method employed. If 
thoroughly done with friction, satisfactory 
results generally follow, and the effect is 
enhanced if special attention is directed to 
the heavy muscles of the back, as empha- 
sized by Hare. Benefit from tepid spong- 
ing is largely due to the friction and to the 
evaporation of the film left upon the surface. 
An analagous effect is from the modified 
pack, consisting of a folded sheet wrung 
out of cool water, extending from the ribs 
to the ankles and sprinkled or renewed 
every three hours. But little mention is 
found of sponging with hot water to reduce 
fever, yet it is often effectual and also pleas- 
ant to the patient. My first experience 
with the method was in the case of my own 
daughter. I called in a colleague and de- 
voted my entire time to nursing, as her 
condition was alarming, with fever exces- 
sively and continuously high. We did not 
use the Brandt bath, but did use the cold 
pack with ice, ice coil and ice cap, spong- 
ing and various forms of application 
thoroughly with disappointing results. Re- 
tnembering the fall in temperature 1 had so 
often noted in infants following the hot 
bath, I determined to try the experiment of 
sponging with hot water. 1 folded the 
gown up under the arms, placed a blanket 
nexl to the patient and with flannel cloths 
wrung out of water as hot as my hands 
could bear I sponged the body and lower 
limbs under the blanket, first wiping my 
hands on a towel after wringing the cloths, 
to prevent dripping. The reduction of tem- 
perature was prompt, and the effect upon 
the nervous system was equally satisfactory. 
I have since used hot sponging to reduce 
fever quite often, and always with confi- 
dence in the asthenic type, with tendency 
to coolness of fingers and at the height of 
the fever, and a disposition to cover up. 
When the temperature begins to Jail, these 
patients will complain of being too warm 
and want to uncover. A sponge of flannel 
cloth is of distinct advantage because of 
the friction produced by this material when 
wet, a point worth remembering in any 
kind of sponging. 

We will consider nexl the problem of 
feeding. The protracted wasting character 
of this disease demands a nutritious diet, 
at the same time we have a feeble digestion 
and faulty assimilation. We meet the 
same difficulty in a dili reul condition, when 
we attempt to feed a delicate baby on an 
artificial food, and in both, are forced to 

the position of doing the best we can and 
not what we desire. I have often tried to 
follow the advice of several high authori- 
ties and feed my Tvphoid Fever cases with 
semi-solids, and each time it has proved a 
mistake. 1 therefore agree with the usual 
teaching that a fluid diet is the correct, one, 
but I do not believe that sweet milk should 
be the principal food as advocated in our 
standard text-books. When diluted half 
with lime water, vichy, apollinaris or even 
plain water, it frequently serves; but I 
challenge the experience of every man to 
prove the assertion that as usually given 
sweet milk will not agree with 10 per cent, 
of his cases, and that the remainder will 
be seriously jeopardized by its continued 
feeding. Even when diluted as suggested, 
its digestibility cannot be affirmed without 
a trial, and admitting that it will agree, it 
must be remembered that the nutritive value 
of a given quantity of the mixture is les- 
sened in proportion to the amount of dilu- 
tion. Experience teaches me that sweet 
milk is a dangerous food in Typhoid Fever, 
and on the other hand that buttermilk is 
the safest, most dependable form of liquid 
food at our command. The more rigid the 
comparative tests the more positive will be 
the evidence of its practical superiority, as 
we could expect from theoretrical deduc- 
tions; for buttermilk contains all the nutri- 
tive elements of sweet milk except the fat. 
But the casein, which gives so much trou- 
ble in sweet milk feeding, is changed into 
a lactate in buttermilk, easily digested and 
assimilated. If we desire' to retain the fat, 
compressed tablets of Lactic acid bacteria 
are on the market by the use of which but- 
termilk retaining all the cream, is at our 
command. It should be fed fresh, and the 
addition of a small amount of sodium 
chloride will render it more palatable to 
many and keep the system supplied with 
this necessary salt. My argument is not for 
an exclusive use of this or any other one 
food; but rather a plea for its selection as 
the principal one, to be alternated with 
expressed beef juice, etc., to relieve the 
monotomy of an unchanged diet. 

Intestinal elimination is the last of the 
great triology left for present consideration. 
Men of long experience differ widely in 
opinion on this point. Personally. 1 am 
an advocate of free intestinal elimination 
in Typhoid Fever. The clinical evidence 
is so positive in favor of this position, I can 
but believe that those who oppose it have 
understood the term to mean "drastic pur- 
gation," which is not the case. Several 
stools a day do not necessarily indicate suffi- 
cient elimination, for frequently these may 
be from the lower bowel entirely, leaving 
the rest of the canal inactive. This stasis 



of the faecal current results in fermenta- 
tion, gaseous distention, increased stub- 
bornness of fever, poor digestion, delirium 
and other symptoms of auto-intoxication. 
Locking the bowels for days at a time with 
opiates after intestinal hemorrhage, illus- 
trated the harmful influence of poor elimi- 
nation on the patient, for the rapid increase 
in severity of constitutional symptoms can 
but rarely be attributed to the amount of 
blood lost. I am convinced of the benefit 
obtained by the judicious use of intestinal 
antiseptics, but the most ardent advocate of 
this method of treatment will be disap- 
pointed in results if intestinal elimination is 
inadequate. While so important, the means 
used should be selected with judgment and 
effects carefully watched. The dose of 
drug given for this purpose must be in accord 
with'the fact, that in this disease an ordinary 
laxative amount will act as a drastic purge. 
A teaspoouful of castor oil in the morning 
will ordinarily suffice to produce a satisfac- 
tory result. If first washed with boiling 
water it is not so repugnant to taste, and 
won't gripe. Salines sometimes act better, 
but whatever the selection of drug, the 
dose should be measured to obtain sufficient 
elimination only, and repeated just often 
enough to maintain it. Mention of elimi- 
nation by skin and kidneys has been omit- 
ted because these are rarelj'- neglected ; be- 
sides no attempt has been made to discuss 
anyone of the divisions fully. Really the 
paper is in the nature of a special plea for 
hot sponging to reduce fever when indicat- 
ed, buttermilk as a specially suitable form 
of food and the great importance of intes- 
tinal elimination. Every case of Typhoid 
Fever has its peculiarities to which treat- 
ment must be adapted, just as in other 
diseases, for routine in medicine means the 
end of improvement. I therefore urge no 
hard and fast rules, but rather offer the 
teaching of personal experience with the 
hope that others may find some serviceable 
suggestion which will be of real value in 
the treatment of this serious malady. 

Trunecek's Serum In a Case of Arterio- 

By C. T. vSt. Clair, M. D., Tazewell, Va. 

On November 15th, 1906, I was called to 
see J. R. L., a man of fifty-two years of 
age, for relief from a distressing tightness 
in the chest. Past history, practically 
negative, so far as illness was concerned. 
He had always been a man of good habits; 
a hard working farmer for many years; 
afterwards, a contractor, and had done a 
great deal of heavy lifting and carrying, 
and had been exposed much in bad weath- 

tRead before the Va. Med. Soc. Chase City, Va. 

er. lie was a man of good physique, and 
well nourished. He had felt a peculiar 
tightness in the chest for more than a year, 
which so interferred with breathing that he 
had been compelled to set up a good part 
of each night for the past few months. He 
found himself out of breath after slight 
exertion, and when I first saw him. he ex- 
pressed it as, "the breath is just beyond my 
reach," or, "I seem to be breathing under 
heavy wet blankets." His pulse was hard 
and full, tension high, arteries sclerosed. 
No valvular organic heart lesion, but hy- 
pertrophy; urine, negative, except for slight 

Diagnosis : — Arterio-sclerosis. 

I gave him Potassium Iodide and Nitro- 
glycerine for weeks; with little or no relief. 
The tension in the arteries became alarming- 
ly high, and could be controlled only by vene 
section. The Nitroglycerine and Iodide of 
Potash, together with milk diet and rest 
were continued for several weeks, with but 
little relief. It became impossible for him 
to lie down at night without having had a 
hypodermic of morphine; however, the 
dose of this drug was kept below one grain 
until late in the disease. 

< )n January 19th, 1907,1 gave him 1 c. c. 
of Trunecek's serum, hypodermatically. 
The following day, I gave 2 c. c, and 3 
c. c. the next day; thus increasing, until, 
on January 23rd, he had 5 c. c. of the 
serum. I then dropped back to 3^2 c. c. 
two days later, then 5 c. c. again the next 
day, then 3 c. c. two days afterwards; and 
was for a long time thereafter able to con- 
trol the symptoms with 1/2 to 2 c. c, given 
at intervals of several days. 

The effect of this treatment was nothing 
short of marvelous. The relief from labor- 
ed breathing, and the quiet sleep following 
were perfect. The patient gained strength, 
weight and vigor, and was able to return to 
work. The serum was continued during 
the rest of the month of January, through 
February, and to the 15th of March, how- 
ever, his old symptoms of dyspnoea return- 
ed, and gradually grew worse. He could 
not be relieved by the serum, or any of the 
usual remedies for this ailment. Dyspnoea 
became more and more distressing, sleep 
still more disturbed, and in the meantime, 
the arteries were more selerosed; Cheyne- 
Stoke's breathing the most pronounced I 
ever witnessed. There were convulsions 
from superimposed uremia, and finally the 
dilated heart failed, and the patient died 
about three w r eeks later. 

My sole object in reporting this case is 
that I am aware that is a new remedy, so 
far as most of us are concerned, and I am 
anxious to know if any present have used 
it in like affections, and to know their ex- 



perieuce with it, and also to rail attention 
to a remedy, which in my hands, was a mar- 
vel in relieving the distressing symptoms of 

this malady. This patient told me repeat- 
edly that he could feel the good effects of 
the treatment in less than five minutes after 
its administration, and from what 1 have 
been able to learn of it, I believe, had it 
been used earlier in the disease, probably 
life would have been much prolonged. I 
am now sure that the failure of the remedy 
to continue to relieve, was because the 
heart dilated to such an extent that it was 
impossible for it to continue its function. 

The relief in this case could not have been 
psychicalal.for, as stated before, the patient 
could not possibly lie down, and sleep was 
ible, without the use of morphine 
hypodermically.and during the time he was 
taking the Trunecek's serum he did not 
have a single dose of the opiate. 

The serum, so-called, is the equivalent 
of blood plasma, ten times concentrated, 
and its formula is : 

Sodium Sulphate . 0.44 

Sodium Chloride . 4.92 

Sodium Phosphate . 0.15 

Sodium Carbonate . 0.21 

Potassium Sulphate . 0.40 

Aquae Dist. q. s. ad. . loo. on 

As you would naturally suppose, the 

administration of this mixture under the 

skin was usually attended with a great 

deal of pain, which subsided, however, in 

a few minutes. 

I have been able to find but very limited 
literature upon this subject, and 1 shall 
gladly hear anything concerning its use. 

Importnnceand Treatment of Mjalftia. 

Peritz emphasizes the importance of dif- 
ferentiating between neuralgia and myalgia, 
especially on account of the liability of the 
latter to be mistaken for an affection of 
some vital organ, and directs attention to 
the efficacy of proper treatment. The pain- 
ful points in neuralgia generally correspond 
to the points at which the nerve emerges 
from tlu- bone or comes toward the surface. 
In myalgia, the pain is usually located in 
the muscle itself , and is always distributed 
over a much larger area than in neuralgia, 
while the tenderness persists during the in- 
tervals between the attacks of pain. There 
is also generally a zone of hyperalgesia 
above tin- affected muscles, but it does not 
parallel the course of the nerves. The 
myalgia generally develops by preference 
where the muscle is thinnest and most ex- 
posed. In the writer's illustrations the 
myalgic points are seen to correspond to the 
points where the muscle blends into its ten- 
don, and they are generally at the edge of 
the muscle. 

Myalgia has been found by the author to 
be rebellious to electricity, massage, and 
the salicylates, but has always yielded 
promptly to injections of a 0.2 per cent, 
physiologic salt solution, directly into the 
muscle. Several injections are made at dif- 
ferent points over the painful area, and re- 
peated later if necessary. In one instance, 
an elderly patient was suddenly attacked 
with pain in the precordial region, which 
recurred spasmodically several times a day 
and radiated into the arm. Nothing abnor- 
mal could be found in the heart action ex- 
cept a rhythmic dropping of every fourth 
beat. The writer was able to determine 
the existence of myalgia of the upper part 
of the free margin of the pectoralis major. 
Injection of the salt solution cured the my- 
algia and the nervous symptoms, including 
the cardiac arryhthmia, also varnished. 

The author thinks it probable that the 
form of angina pectoris in which benefit is 
obtained from massage is probably myal- 
gia. In the epigastric region it is liable to 
be mistaken for a stomach trouble. The 
affected part of the rectus muscle may exert 
pressure on the stomach, especially when 
that organ is distended after a meal, pro- 
ducing symptoms simulating "nervous 
dyspepsia." The reflex symptoms of myal- 
gia may include headache and vertigo and 
pains in the compensating sound muscles, 
as in myalgia of the gluteal muscles, in 
which the pains are generally referred to 
the outside and calf of the leg. — Berliner 
klinische Wochenschrift. 

Why Must Appendix be Removed In Gyne- 
cological Operations? 

Paukow (Munch, med. Woch., ) discus- 
ses the necessity of a routine removal of 
the appendix whenever the abdomen is 
opened for a gynecological operation. The 
author has made systematic histological 
examination of the appendices removed 
from patients operated upon for gynecolo- 
gical lesions in 150 cases. He finds that 
the appendix is affected more often in the 
female than in the male, and that lesions 
occur in 60 per cent, of gynecological cases. 
Appendicitis plays a much wider role in 
gynecological cases than has been supposed. 
It is frequently the cause of closure of the 
tube and resulting sterility. Many cases of 
pain in the right side referred to the ovary 
result from appendicitis. The inflamma- 
tion of the appendix is frequently unobser- 
ved by the patient, yet it leaves its marks 
behind in adhesions, and chronic inflamma- 
tory conditions. Hence the author believes 
that when we have opened the abdomen for 
another operation we should at the same 
time remove the appendix. 



Charlotte Medical Journal 

No. 36 South Tkyon Street. - - - - 
Charlotte, N. C. 


The tenth annual meeting of this pro- 
gressive medical association will be held at 
Charlotte, N. C, February 18-19, 1908 un- 
der the Presidency of Dr. Stuart McGuire, 
of Richmond, Va.; Dr. J. Howell Way, 
Waynesville, N. C, is Sec'y-Treas. This 
Association comprises in its membership 
manv of the leaders of the profession in the 
three states, and is assured of a cordial 
welcome to Charlotte. It was in this city 
some ten years ago the first regular annual 
session was held. 

Both President and Secretary are active- 
ly at work to secure an elaborate program 
and a full attendance, and a large number 
of excellent papers from leaders of the pro- 
fession are expected. 

The subject of the Annual Debate is 
"Epilepsy" and the personnel of the "lead- 
ers of Debate," Drs. J. Allison Hodges, 
Richmond, Va.; J. P. Munroe, Davidson, 
N. C; and Dr. T. P. Whaley, Charleston, 
S. C, assures an instructive discussion of 
this important subject. 

Headquarters will be at the Selwyn 
Hotel. The Local Committee of Arrange- 
ments are: Drs. E. C. Register, Jno. R. 
Irwin, R. L. Gibbon, all of Charlotte, N. C. 

A cordial invitation is extended to all 
members of the State Societies to be pres- 
ent, membership in the Tri-State being 
limited to members in good standing in 
their respective State Societies. 

Gentlemen contributing papers who have 
not done so, should promptly send their 
titles to the Secretary. 


Pennsylvania has set aside the sum of 
$1,000,000 for the purpose of building and 
maintaining a sanatorium for the care of 
indigent consumptives. It is said that the 
State owns a forest reserve containing 
about 50,000 acres on which the institution 
will be established. 

Other States are taking steps in this 
direction also; some have already done so. 
Our own State of North Carolina recently 
appropriated $15,000 for this purpose and 
the land has already been purchased in the 
pine regions of the East. In addition 
Sr>,0i to annually for maintainance was set 
aside. Soon we will have at least a small 

sanatorium where those consumptives un- 
able to procure proper treatment may be 
sent, segregated and cared for. While the 
sum allotted to this institution is small, it 
nevertheless means a start and the good it 
may accomplish is beyond calculation. 

It is something of which North Carolina 
should feel proud that we were among the 
first to take active measures toward the 
eradication of tuberculosis. The public 
wellfare, charity, : and humanity are con- 
siderations which prompt citizens to prose- 
cute a work of this kind. As a matter of 
opinion, we attribute this awakening and 
the active measures taken by Legislatures 
of the various states to the thorough dis- 
semination of knowledge concerning the 
disease among the laity. Teach people, 
make them understand and they will not 

The fact that tuberculosis is a prevent- 
able disease and the active warfare now 
being originated in every quarter against it 
cannot but arouse the belief that the day is 
not for distant when its ravages will be 
under man's control. 

Elsewhere in this issue is contained an 
announcement concerning the great world 
conference on tuberculosis to be held in 
Washington, D. C, in September, 1908. 
The world has never witnessed such a 
spectacle as this, and we believe that it is 
not a Utopian dream when the prophesy is 
uttered that the reign of the great while 
Death will ultimately come to an end. 


Attention has been called most interest- 
ingly by Corson, of Savannah, to a modifi- 
cation of the classic operation for liver 
cirrhosis advocated by Talma. The op- 
eration is very simple, can be done under 
local anesthesia and is followed by remark- 
ably good results. According to Dr. Cor- 
son the peritoneum is opened through a 
small incision in the mid-line just below 
the ensiform cartilage, a bunch of omentum 
is picked up, drawn out, and tucked under 
the skin, and stitched in place with a few 
catgut sutures. The incision in the abdo- 
men is carefully sewed in layers around the 
base of the omental mass, sufficient to close 
the abdomen, yet avoiding any constrict- 
ion of the omental tissue itself. The op- 
erator, as he sees fit, may do a one-sided 
operation, or he may pick up a second 
bunch of the omentum and suture it in on 
the opposite side, should he think it neces- 
sary to increase the area of transplantation. 
Narath claims for this method that results 
are very quickly apparent: the subcuta- 
neous veins become prominent in a week, 
and the relief to the obstructed portal cir - 


culation is seen at once. 

The principle involved in this and the 
original Talma operation is identical. 
An effort is made to increase the collateral 
circulation and thus provide a route 
through new vessels by which the 
portal blood can reach the heart. 
Talma united the upper surface of the liver 
to the opposing surface of the diaphragm, 
but this method has not proved so efficient 
as uniting the omentum to the anterior ab- 
dominal wall, either by stitching it to the 
peritoneum, or preferably by its subcuta- 
neous insertion as done by Narath. By 
the latter procedure the portal vessels of the 
omentum are brought into direct contact 
with the tissues in which the superficial 
abdominal veins lie, and a more direct col- 
lateral circulation is thus established. The 
evident enlargement of the superficial veins 
of the abdomen within a week shows how 
quickly this occurs. 

The only inconvenience resulting from 
Narath's operation is the epiplocele and 
possibly hernia which may develop. 
As compared with Talma's method — the 
mortality of which is 10 per cent. — 
the mortality is little or nothing. This 
with its great simplicity should recommend 
it. Doubtless more will be heard cf the 

The Bickett commission appointed by 
the last legislature to look after the estab- 
lisment of the hospital for epileptics met in 
Raleigh Jan. 2, '08. It will be remembered 
that this commission some time since pur- 
chased an extensive tract of land known as 
the Grimes' Land, containing 1250 acres, 
near Raleigh, on which to establish such 
an institution. Since that time however it 
has been decided not to carry out these 
plans because of the objections on the part 
of the municipal authorities of Raleigh, 
that the water-shed from which the city 
gels its water supply will be damaged. 
Just what disposition is being made of the 
matter of establishing this hospital the pro- 
fession at large would be pleased to know 
more particularly. It means a great deal 
to the whole State that such an insti- 
tution is assured and we are anxious to see 
its consummation in the near future. 

We are informed through the lay press 
that it has been decided to establish a colony 
of one hundred al the Central Insane Hos- 
pital, Raleigh. Also a new nurses' build- 
ing is to be added to the present buildings 
at Morganton, and a small addition to the 
hospital for negroes at Goldsboro. Wheth- 
er these improvements are to be carried out 
according to the plan laid down in the 
Bickett measure we do not know. 


Charlotte and surrounding communities 
are in the throes of a disorder commonly 
and familiarly known as "Grip." It lias 
been estimated that there were 2,500 cases 
in the city at one time. Every family, it is 
safe to say, has its sufferers and while the 
estimated number may be an exaggeration 
still it is indicative of the prevalence of the 
disease. There is no way by which accu- 
rate figures can be obtained for verv ob- 
vious reasons. We of course are but suf- 
fering with the rest of the country. For 
weeks past accounts of its presence in 
various cities and towns have warned us of 
its swift approach. And now it is upon us 
with a hurricane-like explosion. 

As to the prevailing type we are unpre- 
pared to make any definite statements, yet 
there are some severe cases reported with 
an occasional case of puuemonia as a com- 


On Feb. 5, '08, the House of Represen- 
tatives of the South Carolina Legislature, 
now in session, passed by a large majority a 
bill providing for the appointment of a 
State Health officer at a salary of $3,000 
and with large powers. The passage of 
this measure is a decided movement in the 
direction of better sanitation and the pro- 
phylaxis of contagious and infectious dis- 

The bill provides for the appointment of 
the State health officer, who must be a 
practicing physician, graduate from a rep- 
utable college and experienced in public 
sanitary matters, by the executive commit- 
tee of the State health board, whose secre- 
tary he shall be. He "shall have power to 
declare, when the facts justify it, any 
place to be infected, ' ' and take all necessary 
steps to prevent the spread of disease from 
the infected locality. 

Section 4 provides that "The State board 
of health shall have power through its 
health officer to impose upon all railroads 
and navigation companies, vessels or cars, 
such restrictions and regulations as to in- 
spections or sanitary rules as in their judg- 
ment may be necessary to protect the health 
of the people of the State." 

It is said that the local boards of health 
have proved ineffective in South Carolina 
ill important instances on account of local 
men of influence getting in the way. 


Drs. E. R. Russell and J. P. Mathesou 
have formed a partnership for the practice 
on diseases of the eye, ear, nose and throat. 
Their office was opened Feb. 6, '08, at the 



place occupied by Dr. Russell during the 
past several years. 

After several months holiday, Dr. Russell 
returns to his work with renewed energy and 
strength. lie is looking quite fit and is 
his same old genial self. Dr. Russell is 
well known throughout North Carolina and 
adjacent States, having engaged in the 
practice of his specialty for a number of 
years during which time he has established 
an enviable reputation. We are most 
heartily glad to welcome him and rejoice in 
his restoration of health and strength. 

Dr. Matheson has practiced medicine in 
Charlotte for several years. At one time 
he was resident physician to the Presby- 
terian Hospital, later he engaged in general 
practice and succeeded in building up a 
lucrative practice. Since September '07, 
he has been doing special work in the 
branches to which he, with Dr. Russell, 
will devote his attention in the future. For 
several months he has pursued his studies 
in the clinics of Northern cities. Conse- 
quently he begins his special work splendid- 
ly equipped. 

Both these gentlemen are active, ener- 
getic, scientific physicians. The combina- 
tion makes an unusually strong firm. We 
congratulate them and add our good wishes 
for their success. 


At the annual meeting of the Southern 
Medical College Association held in New 
Orleans recently, three medical schools 
were added to the membership, viz.: the 
Atlanta College of Physicians and Sur- 
geons, the Medical Department of the Uni- 
versity of Kansas, and the College of Phy- 
sicians and Surgeons of Little Rock, Ark. 
Officers for the ensuing year were elected 
as follows: President, Dr. Christopher 
Tompkins, dean of the Medical ' College of 
Virginia; vice-president, Dr. W. S. Rogers, 
dean of the Memphis Hospital and Medical 
College; secretary and treasurer, Dr. L. C. 
Morris, of the Birmingham Medical College; 
chairman of the executive committee, Dr. 
J. S. Cain, of Sewauee, Tenn. 


In the "American Jounal of the Medical 
Sciences" (June, 1909) we find an article 
by Drs. Warren Coleman and B. II. Buxton 
on the presence of the Bacillus Typhosus in 
the blood of cases of typhoid fever. The 
number of cases reported to date in which 
bacteriological examinations of the blood 
of typhoid and suspected cases have been 
made is L602. < )f this number 75 per cent, 
gave a positive result. These results com- 

pel the conclusion that the typhoid bacillus 
is present in the blood in every case of 
typhoid fever and that failure to recover it 
is due to error of technique. The dimin- 
ishing percentages in the latter weeks of the 
disease do not indicate that the bacillus has 
disappeared from the blood in the negative 
cases, but point rather to diminishing num- 
bers of bacilli, whose presence imperfect 
methods have failed to reveal. All investi- 
gators except Conradi are agreed that the 
bacillus disappears from the blood at or 
about the time the temperature falls to nor- 
mal. Conradi claims that the bacillemia 
persists into convalescence. 

If future observations confirm the con- 
clusion that the typhoid bacillus is present 
in the blood of every case of typhoid fever 
throughout its course, the current concep- 
tion of the patho-genesis of the disease 
should be modified. Typhoid fever can no 
longer be regarded simply as an infection 
of the body with typhoid and related bacilli. 
The typhoid bacillus may be present in the 
body and actively growing, yet the patient 
not have typhoid fever. It has been shown, 
for example, that the bacillus may live and 
multiply in the intestine of healthy persons. 
The patient is infested and a menace to 
others, but is not infected. The number of 
cases of biliary infection with the typhoid 
bacillus, without a previous or existent 
typhoid fever, is fairly large and is increas- 
ing. In the post-typhoid bone and other 
inflammatory lesions the lodgment and 
growth of the bacillus do not produce the 
characteristic symptoms of typhoid fever, 
in spite of the fact that large amounts of 
endotoxin should be liberated and absorbed 
when the abscesses are multiple. 

The very term used to describe these 
conditions, "post-typhoid," indicates that 
the typhoid fever perse has subsided. The 
temperature curve conforms to the so-called 
septic type. Therefore it seems that 
to produce typhoid fever the bacillus 
must not only be present in the 
body and growing, but that it should grow 
in a situation whence it has free access to 
the blood. In typhoid fever the bacillus 
first finds its way from the alimentary tract 
to the lymphopoietic system, including the 
spleen, where it develops chiefly and from 
which it invades the blood stream. This 
observation, together with the fact that the 
bacillema persists throughout the disease, 
suggests the following view of the patho- 
genesis of typhoid fever. That the disease 
is caused by the destruction of vast num- 
bers of baccilli in the blood, with the liber- 
ation of their endotoxins, and the consequent 
reaction on the part of the host. When 
the endotoxins are liberated elsewhere in 
the body, e. g. in abscesses, the symptoma- 



tology is not that of typhoid fever. 

The analysis of the cases in the various 
weeks of the disease suggests the following 
relationiof the bacillemia to the course of 
typhoid fever. In the earlier stages the 
bacillus invades the blood in greatest num- 
bers. Later, as the disease is approaching 
a favorable termination, the diminution 
in the number of bacilli in the blood is sim- 
ply an index of less active development in 
the lymphatics and spleen. If the disease 
in any case pursues a long-duration course, 
that beyond the usual three weeks, the 
bacillus may be recovered from the blood 
so long as the temperature persists. While 
the bacilli disappear from the blood at or 
just before defervescence, it is improbable 
that all the bacilli in the body have been 
destroyed. Otherwise, relapses and post- 
typhoid inflammatory lessons would be im- 

The bacillemia apparently bears no re- 
lation to the type or severity of the disease 
except in so far as regards numbers of 
bacilli. The bacillus is found in the blood 
equally, but not with the same persistence, 
in the mild as in the severe cases, and in 
the cases of short as well as long duration. 
The importance of the definite establish- 
ment of the nature of these short duration 
cases can scarcely be overestimated from 
the epidemiological standpoint. The serum 
reaction has done much to clear up their 
diagnosis, but the final proof has remained 
for the bacteriological examination of the 

The blood has been examined bacteri- 
ologically by various investigators in thirty- 
three relapses. The typhoid bacillus has 
been recovered in 90 per cent, of the cases. 
Reinvasion of the blood with destruction of 
the bacilli probably cause the symptoms of 
a relapse, but the underlying conditions 
which inaugurate active development of the 
bacilli after their growth has once been 
brought under control are unknown. 

In conclusion it may be stated: (l) 
That the typhoid bacillus is present in the 
blood of every rust- of typhoid fever through- 
out its course. (2) That the bacillemia 
in typhoid fever does not constitute a true 
septicemia, but it represents an overflow of 
bacilli from the lymphopoietic organs. (3) 
That the clinical picture of typhoid fever 
results only from infection of the lympho- 
poietic organs by the typhoid bacillus, with 
invasion of the blood stream and destruc- 
tion there of vast numbers of bacilli. (4) 
That the endotoxins of the typhoid bacil- 
lus are not cumulative in action and con- 
valescence from the typhoid fever perse is 
established within a few days after the dis- 
appearance of the bacilli from the blood. 


Dr. Lawrence Edward IIolmes> who for 
several years past had been resident physi- 
cian at the Clarence Baker Memorial Hos- 
pital, Biltmore, near Askeville> N. C, died 
Feb. 5. '08, in Biltmore hospital, after six 
davs illness with pneumonia, aged 35 years. 

Dr. Holmes was born in England. He 
graduated from the medical school of Penn- 
sylvania University in 1897 > coming to 
Asheville in 1901. He obtained license in 
North Carolina in 1901 and since that time 
has been in active practice at Biltmore. He 
was a member of the Buncombe county and 
of the North Carolina State Medical So- 
cieties. He was unmarried and is survived 
by a father, two sisters and three brothers. 

Willi the December, 1907, issue the Fort 
Wayne Medical Journal — Magazine ceased 
to exist, it having merged with the Journal 
of the Indiana State Medical Association. 
The first number of the newly combined 
Journals appeared in January. The Jour- 
nal — Magazine had completed its twenty- 
eighth volume. For over thirty years a 
journal had been published at Fort Wayne. 

Review of Southern Medical Literature 

Texas Medical Journal, Dec, 1907. 
Atrophic Cirrhosis of the Liver.— ]j r> 
J. Y. Shoemaker regards the cause of the 
cirrhosis as undoutedly due to alco- 
holism, which is really the most frequent 
cause in all forms of cirrhosis of the liver 
and especially in the atrophic form. — 
The more alcohol c o n t a i n- 
ed in the beverage used the more apt and 
the sooner is the disease developed. Alco- 
colic drinks taken before meals on an emp- 
ty stomach has its influence in producing 
the disease more rapidly, the alcohol being 
absorbed more rapidly in an empty stomach 
than when the stomach is partly filled with 
food. Among the other predisposing causes 
are the chronic disease which favor con- 
structive tissue formation such as syphalis 
gout tuberculosis and carcinoma age and 
the male sex have their influence. The 
disease seldom occurs before middle life. 
Treatment: This patient owing to the large 
amount of fluid in his abdominal cavity is 
obliged to remain in bed. His diet con- 
sists of milk and broths, no solid food or 
anything that tends to irrite the gastro- 
intestinal canal should be given this patient. 
To keep his skin active he receives frequent 
warm baths followed by alcohol rub. He 
is inclined to be constipated hence we first 
gave him a grain and a half of calomel in 
broken doses, followed by a saline purge. 



Cathasis, diuresis and diaphoresis are all 
indicated hence Niemyer's Pill was prescrib 
ed which contains Powd Scilla Massa Hy- 
drargyri and Pulv. Digitalis each one 
grain. One pill to be given every four 
hours, It has decreased the ascitic con- 
dition somewhat, but should medicinal 
agents fail to reduce the ascites materially 
paracentesis abdomenis would be resorted 
to draw off the fluid after all necessary 
aseptic precautions are taken, thebadder is 
emptied, the patient is placed in a sitting pos 
ture and trocar is quickly thrust through 
the already anestheized area over the linea 
alba about three inches above the pubis. 
The trocar should not be inserted more 
than one inch. After the proper amount 
of fluid is drawn off gradually, the wound 
is covered over with a small thin plaget 
of cotton saturated with collodion. Pres- 
sure may be made over the abdomen by a 
proper binder, but it has little or no value. 

list of eligibles. Even a divy was expected 
from the undertaker it is said if medical 
services proved unavailing. Comment on 
the state of morals in the medical and 
pharmaceutical profession of San Francisco 
is entirely unnecessary. There is no doubt 
but that any contract between physician 
and druggist or other tradespeople whereby 
a commission is given or asked is illegal 
and against public policy. If a physician 
sends all his prescriptions to a neighboring 
drug store and gets 15, 20 or 25 per cent, 
on them, he will in all probability prescribe 
more often than is necessary in greater 
dilutions and in doses of larger bulk. 

Nashville Journal of Medicine and Sugeiy, 
Dec, 1907. 
Secret Commissions.— jj r H. S. McRee 
s ays that San Pranscisco suffered for the 
s in of commissions on prescriptions, as 
well as many others, at the great earthquake. 
The pharmaceutical press contained a 
statement of the bad conditions there, 
which, thinking them over drawn, was 
sent to one of the prominent physicians in 
San Francisco with a query as to the truth. 
His reply was that there was too much 
truth in it. He said that the doctors had 
in mind to fight the custom some day, but 
were too busy now with the patent medi- 
cine fraud to take up further conflict. The 
statement was to the effect that some years 
ago a drug store was started in San Fran- 
cisco, but, unfortunately lost money from 
the beginning. After a time the proprietor 
packed up his stock moved to New York 
city and now has one of the most success- 
ful drug stores in the Eastern metropolis. 
Why was the drug store such a success in 
New York after proving such a failure in 
San Francisco? Here is the secret of the inci- 
dent mentioned. The pharmacist whose busi- 
ness venture proved so successful was com- 
pelled to move from San Francisco because 
he refused to pay tribute to the physicians for 
the privilege of filling their prescriptions. 
According to authority on the matter there 
was only one drug store in San Francisco 
which does not give a percentage to 
some physician for prescriptions filled. 
Tribute is not only laid upon the pharma- 
cist, but we are told that even the trained 
nurse must turn over to the physician the 
half of her first week's salary in each case 
in order to have her name placed on his 

The Mobile Medical and Surgical Journal, 

November, 1907. 
The Stomach Tube. — rjr. A. T. French 
believe the great advancement we have 
made in the knowledge of gastric diseases 
is due to the introduction of the stomach 
tube and to modern technique however that 
which may be indispensable from a diagnos- 
tic standpoint may become a dangerous thing 
when used as routine practice. The stom- 
ach tube is not a cure all, nor can it be used 
without fear of harmful results in every 
case. It use is contra-indicated in the fol- 
lowing diseases; injuries to the throat and 
oesophagus; heart disease; advanced cases 
of tuberculosis; cancer of the stomach; 
and ulcer of the stomach. It should be used 
with extreme caution whereever there is 
a history of vomiting of blood. The 
stomach tube has been most beneficial to the 
author in the following cases. In the early 
stomach symtoms of tuberculosis cases the 
plain hot water wash was used daily at 
bed-time and gives excellent result, (l) 
In acute gastritis in adults and children. 
(2) In catarrhal gastritis the following 
case is reported: J. B. D. suffered for two 
years with vomiting and food regurgitation, 
mucous vomiting and passed from the 
bowels 'in large quantities, with diorrhoea 
and great weakness. Could eat but little 
food without fermenting, souring produc- 
ing the rotten egg belch and diorrhoea. He 
was greatly reduced in flesh when washing 
of the stomach was begun. After using 
the tube from once to twice a week for a 
year he was entirely relieved and now three 
years after he can eat anything and do 
any man's work. He has not used the 
tube in the past three years. 

(3)Chronic gastritis, due to the abuse of 
alcohol the stomach of the old toper is 
greatly benefited and helped by washing 
with hot water with a teaspoonful bicarbo- 
nate of soda. (4) Gastric neurosis (5) 
ulcers of the stomach; the use of calcium 
chloride in the wash water acts well. (6~) 
Hyperchlorhydria. : author finds silver ni- 



trate solution, one to one thousand gives ex- 
cellent results. (7) In gastric fermentation 
one ounce of salicylic acid dissolved in four 
ounces of alcohol and one to two teaspoon- 
fuls of this to each quart of hot water 
gives great relief. 

The American Practioner and News, Dec. 
Diagnosis and Treatment ol Tuberculo- 
sis ol the Kidney. -Dr. J. M. Morris says 
that tuberculosis of the genito-urinary tract 
almost university begins at one of four 
points. The kidney prostate epididymis 
or tubes. Tuberculosis of the bladder is 
seldom primary but is usually secondary to 
tuberculosis of the kidney prostrate or epe- 
didymis. It was formerly believed that 
tuberculosis of the prostrate was very rare 
or did not occur at all but later research has 
proved the contrary to be true and that it is 
often affected primarily. So also of the 
epididymis and tubes both being frequen- 
ly the seat of primary tuberculosis. Tuber- 
culosis of the kidney occurs at all ages but 
is most common between the ages of twenty 
and forty. Statistics show that women are 
oftener afflicted than men. The symptoms 
of renal tuberculosis vary greatly in differ- 
ent cases. One of the most common symp- 
toms is frequent micturetion — this frequent- 
ly not being very marked as a rule but the 
patient will notice a somewhat frequent de- 
sire to urinate. Pus and blood in the urine 
art- symptoms of great importance. Blood 
does not occur in all cases. Most frequently 
it occurs in very small quantities, frequently 
being microscopic. The urine is frequently 
cloudy, pus occurs in varying amounts and 
when extending over a long period of time 
should always excite suspicion of the dis- 
ease. In well marked cases, as in tuber- 
culosis elsewhere in the body, grave symp- 
toms occur, anrima, loss of flesh and 
strength and a general debilitated condi- 
tion. For the diagnosis of renal tuberculo- 
sis a knowledge of three things are essen- 
tial, namely: The use of the cystoscope, 
catheterization of the ureters, microscopic 
and chemical analysis of the urine. The 
needs for the use of the cystoscope are 
first, to determine whether or not the dis- 
ease has extended into the bladder, in 
which event an operation for the removal 
of the kidney would be doubtful. — 
Also careful inspection of the mouth 
of the ureters is necessary for in tu- 
berculosis of the kidney there are small 
shallow ulcere present around the opening 
resembling foot prints in the snow. Cathe- 
terization of the ureters is of the utmost 
importance in this disease without it a pos- 
itive diagnosis cannot be made for no man 
can judge in any other way whether the pus 

and blood comes from one kidney or both . As 
to the treatment of tuberculosis of the kid- 
ney, the removal of the kidney is the 
only thing to be done when the disease is 
confined to one kidney and no operation 
known to the surgeon offers more hope to 
the patient than this one. 

Atlanta Journal-Record of Medicine, Dec, 
Cholecystitis with Special Reference 
to Etiology and Diagnosis. -p r f j? p t_ 

ter after reviewing the subject of etiology 
of cholecystitis concludes : That the most 
probable cause of infection of the gall blad- 
der is not through the intestinal walls, nor 
through the hepatic tissue, nor through the 
duodenum through the hepatic ducts, but 
through the blood of the portal system; and 
from this source one has the catarrhal 
and parenchymatous inflainations with 
occasional empyema, but sometimes malig- 
nancy caused by the presence of stones. 
The symptoms are not all present in any 
one case because different forms and stages 
give different symptoms. Among the most 
prominent symptoms is tenderness immedi- 
ately under the ninth intercostal cartilage. 
This in the author's judgement, is as valua- 
ble a symptom as tenderness in the region 
of McBuruey 's point of appendicitis. The ten 
derness may extend down for 2 or 3 inches. 
To elicit it, press the fingers up under the ribs 
and require the patient to take a deep in- 
spiration. He will complain of pain and 
in many instances if the fingers are firmly 
held, the inspiration is suddenly stopped, as 
though there had been a sudden attack of 
pleurisy. There may be some swelling or ful- 
ness over the region of the gall bladder, 
and percussion gives a general sense of un- 
easiness. By placing the patient on his 
hands and knees, the gall bladder may 
occasionally be felt to drop forward and 
it can be outlined'especially if it contains 
stones. The stomach is usually deranged 
and the patient not only suffers from indi- 
gestion, but severe gastralgia, that can only 
be relieved by emesis.W neu these symptoms 
are present the author at once suspects chol 
escystitis and stones. There may be slight 
jaundice, frequently none. There may be 
chills and fever sometimes, two rigors a 
day attended with high fever. These chills 
may not return for several days when they 
occur as before and are often diagnosed as 
chronic malaria. Hepatic colic will aid 
in forcing a conclusion as to the presence 
of stones. Still there may be some doubt 
until they are found in the discharges. 
These stones are usually found after an 
attack of colic, and if they have facets up- 
on them, they show that they have had 
companions to rub against. Occasionally 



the gall bladder becomes very much dis- 
tended and will reach as low as Pouparts 
ligament It may be miataken for an ap- 
pendicular abscess and only an exploratory 
incission or asperation enables one to deter- 
mine which is present. 

The Mobile Medical and Surgical Journal^ 
Dec. 1907. 

Modern Surgical Treatment of Exop- 
fhalmic Goitre.-i) r . a. Heineck gives the 
following operative points. 1. It is well to 
prepare patients for some time, to observe 
them and to better estimate their ability to 
withstand operation. Before operation all 
cases should be examined with the laryn- 
geal mirror to determine whether one or 
both larygeals are compressed by the thy- 
roid growth. 2. Use the inverted Tren- 
delberg position. But the neck in that 
position which makes the goitre most ac- 
cessible and which interfers least with res- 
piration". A hard round pillow is put under 
the neck. 3. Kocher's transverse convex 
incision allows of a complete exposure of 
both lobes. From an ultimate cosmetic 
standpoint, it is the best as the usual neck- 
wear will hide the scar. If it is necessary 
to make a section of the steruo-hyoid and 
the sterno-thyroid the Mayos advise that 
this be high, so as to preserve the nerve 
supply to these structures. The savings of 
the posterior capsule protects, in the opin- 
ion of the Mayos, against many of the 
dangers of partial thyroidectomy. The 
saving of the posterior capsule among other 
things lessens very much the liability to 
total parathyroidectomy. According to Re- 
gale after parathyroidectomy, such profound 
disturbances of metabulism occur that all 
efforts on the part of the organism to repair 
are absolutely ineffectual. After comple- 
tion of operation, the cutanous wound 
should be surtured accurately. Drain 
through an opening made below this wound. 
4. Hemostasis must be perfect. Do not 
depend on temporary compression to arrest 
bleeding. It is deceptive when possible tie 
the blood vessels. It ispreferrableto leaving 
clamps in position. Clamps interfer 
with healing of the wound. 

Recovery from all symptoms is neither 
immediate or simultaneous. The first symp- 
tom to subside is the tachycardia. The 
tremor and the nervous and psychical symp- 
toms also disappear quickly. The total dis- 
appearance of menstrual disturbances is of 
good prognostic omen. It takes months 
for the entire beneficence of the operation 
to become manifest. The exopthalmos is 
the last symptom to disappear. The longer 
the period of observation after the opera- 
tion the better appear the results. 

The Southern Practitioner, December, 1907 
Hematuria.-- Dr P Rromberg says that 
in addition to special features, symptoms 
referable to the organ involed are usually 
present; and being unable to improve upon, 
he quotes the statement of Prof. Ralfe: "(1) 
Acute nephritis smoky to dark brown urine, 
persistant for some days, with granular and 
bloody casts and excess of albumen (2) 
Renal calculus: often deep red from ex- 
cess of blood, increased by movement and 
passing off rapidly if the patient be kept 
in bed, so that only a few of blood corpus- 
cles can be seen in the urine; generally 
accompanied by or immediately following a 
severe attack of colic; retraction of testicle 
on side affected. (3) Vesical calculus : 
hemorrhage generally follows undue move- 
ment, especially jolting; badder symptoms 
prominent ; detection of stone by sound. 
(4) Cancer of kidney: hematuria very 
abundant with large coagula, and repeated 
at irregular intervals; generally tumor in 
loin. (5) Cancer of bladder:, frequent and 
profuse hemorrhage; cancer cells in urine 
(?); pain referable to bladder, tumor may 
be discovered with sound. (6) Morbid 
conditions of the blood; hemorrhage often 
profuse, but rarely attended with formation 
of clots; general constitutional symptoms 
manifest. (7) Intermittent hematuria: 
the blood passes at irregular intervals, and 
is generally associated with a considerable 
quantit}' of albumen and a definite rise of 
temperature, history of chill. Local symp- 
toms may however be entirely absent and 
we will find our liabilities often taxed to 
their utmost to find discoverable cause for 
rather profuse bleeding. Cases like the 
one reported in this paper a diagnosis of 
of idiopathetic hermatura was made with 
the possibly renal calculus or purpura. — 
This case refused operation but under the 
influence of gelatin and calcium made a 
complete recovery. 

Maryland Medical Journal, December, 1907. 
Report of the Maryland State Sanit- 
arium --By Dr. H. W. Buckler. 

New Orleans Medical and Surgical Journal 
Dec., 1907. 
A New Mclhod of Enucleation of Eye- 
ball Under Local Anesthesia.— p r jt jj. 

Robin has since 1905 been experimenting 
with a new method of local anesthesia in 
enucleation of the eyeball. It has been 
used with success in thirty four cases both 
in private and hospital practice. The mix- 
ture used, in all cases, consists of ten drops 
of a 4 percent, solution of cocaine, ten 
drops of adrenalin chloride (1.1,000) and 
twenty drops of normal salt solution, mak- 



ing forty drops containing altogether 2-5 of 
a grain of cocaine. With a hypodermic syr- 
inge, ten drops of this mixture are injected 
along each rectus muscle, deeply behind 
the equator of the eye after a five minutes 
wait the operation is performed in the usual 
way. Observations on the first twenty 
cases showed that the method was thor- 
oughly practicable, though not entirely 
devoid of pain. Those who complained of 
pain always referred it to the last stage of 
the operation, that of cutting the optic and 
ciliary nerves : the stages of dividing the 
conjuuctura and tendons being practically 
free from pain. As this seemed to suggest 
the use of a larger amount of the mixture 
ten more drops of the mixture were injected 
deeply around the optic nerve, about a min- 
ute before severing it. This fulfilled all 
expectations. A few of the advantages of 
the method of local over general anesthe- 
sia are : the patient is conscious and by 
that fact stands warded against the awful 
error of removing the wrong eye, an acci- 
dent of which several instances have been 
reported within recent years. The amount 
of cocaine used (2-5 to 1-2 of a grain) is 
almost insignificant and certainly is com- 
parably safer to life than any form of gen- 
eral anesthesia. Finally, the patient seems 
to prefer it for since 1905 they have had no 
trouble in inducing all patients upon whom 
operation had to be done to select this 

an inch in length, should be made in the 
mid-line above the pubis. A rubber tube 
one-half inch in diameter, with openings 
on the side, should be introduced through 
the superpubic opening and carried to the 
bottom of the pelvis. No irragation of the 
abdomen should be practiced, no effort 
even made to spongue out the pus, but a 
voluminous dressing should be applied 
and the patient quickly put to bed in an 
exaggerated and Fowler's position. Saline 
solution should be slowly and continously 
given by rectum, the stomach washed out 
if vomiting is persistent, and the heart and 
kidneys stimulated by the hypodermic use 
of sulphate of spartiue in large doses. The 
difficulty often experienced is to keep the 
patient in the proper position in bed so that 
fluids in the abdominal cavity will be car- 
ried by gravity to the pelvis. Since the 
adoption of the new method two years ago 
the author has had but one death in eighteen 
cases of diffuse peritonitis. In other words 
the change of technique has reduced the 
mortality from over 80 per cent, to 55 per 

Gaillard's Southern Medicine. Dec., 1907. 
Instructions to Those Having Gonor- 
rhea. ]; v Dr. V. C. Pedersen. 

The Southern Clinic, December, 1907. 
Physics, Physiology and Therapy of 
Faradism. ~ H y Dr . H . C. Bennett. 

/ 'irginia Medical Semi-Monthly, Dec. 13th, 

Analysis of the Last Five Hundred 
Cases of Appendicitis Operated on at St. 
Luke's Hospital.- Dr Stuart McGuire un- 
der the section of Appendicitis with diffuse 
peritinitis or cases where there is perfora- 
tion of the appendix and free pus in the 
general peritoneal cavity, says that this 
type until recently has been the terror of 
the surgeon. The old method of opening 
the abdomen, removing the appendix, 
washing out the peritoneal cavity with or 
without evisceration, and making counter 
incisions for multiple drainage was followed 
by a mortality of 80 per cent. There has 
been to the author's mind no recent ad- 
vance in surgery so brilliant in theory or 
so practical in results as the new technique 
of treating diffuse suppurative peritonitis. 
In these cases a short incision should be 
made over the appendix, and the diseased 
organ removed; if it is readily accessible, 
a second incision not necessarily more than 

Virginia Medical Semi-Monthly, Dec. J/iih, 

Principles of Surgery Lecture XLI Tu- 
bercular Abscess— Tubercolosis of the 
Eye, Ear, Nose and Throat; of the Skin, 
of the Mouth, Tongue,Intestines and Rec- 
tum; of the Genital Organs; of the Uri- 
nary Organs.— By Dr. Stuart McGuire. 

Cases of Head Injury With Operation. 
Dr. H. S. Mac Lean, says that in cases of 
head injury requiring operation the treat- 
ment has been to open the skull with a 
three-eighth inch trephine, enlarging the 
opening as required with a De Vilbiss for- 
ceps, which has entirely supplanted the 
large-bore trephine in his hands. Open- 
ings measuring, roughly, three-fourths by 
one and a half inches base been made 
quickly and smoothly with this instrument. 
Drainage is freely used — either small rub- 
ber tubing or tightly twisted strands of silk 
worm gut, packing the bone opening tight- 
ly with gauze — no foreign body has been 
used to replace or stimulate regeneration 
of bone in the closing of the wounds, the 
only procedure being to draw the perios- 
teum as far over the opening as possible, 
allowing it to fall in on the dura mater. 
The cases reported are all young subjects 
and the results have been good so far as the 
regeneration of bone is concerned in the 
wound. The author is prejudiced against 
the use of foreign bodies for replacement 
but should the occasion arise for filling a 



large opening lie intends to do it by trans- 
planting a piece of the outer table with its 
periosteal covering adjacent to the wound. 
In the author's experience with cases of 
this character he has been impressed with the 
remarkable tolerance of the brain to opera- 
tive work and the comparative rarety of 
infection. In all cases free drainage was 
used for the first thirty-six hours. So 
strongly has this impressed the author that 
he is inclined to advise trephining in place 
of lumbar puncture in cases of cerebro- 
spinal meningitis when decompression is 
indicated. He would certainly prefer a 
small trephine opening in meningitis cases 
where the symptoms pointed to a prepon- 
derance of cerebral involvement. Five 
very interesting cases are reported in this 

Book Notices. 

Proceedings of the American Medical Edi- 
tor's Association. Thirty-eight annual 
meeting held at Atlantic City, N. J.. 
June 1-3, 1907. Published by the Secre- 
tary, ninety-two William street, New 
York, 1907.' 

Manifesto de la Komnuista Partie. The 
Communist Manifesto. By Karl Marx 
and Frederick Fngels. Authorized Eng- 
lish translation. Edited and Annotated 
by Frederich Engels. Chas. H. Kerr & 
Co., Chicago, 1908. 

Preliminary Announcement of the Inter- 
national Congress on Tuberculosis. 
Washington, D. C, U. S. A., Sept. 21 to 
Oct. 12, 1908. 

Applied Physiology, a Manual of Patho- 
logical Physiology, showing the func- 
tions of the various organs in disease. 
By Frederick A. Rhodes, M. D., Profes- 
sor of Physiology, Medical and Dental 
Departments, Western University of 
Pennsylvania. $2.00 prepaid. Medical 
Press, Pittsburg, Pa., 1907. 
This work by Dr. Rhodes is unique. So 
far as we know there is no other book of its 
kind in existence. For both student and 
practitioner the book is practical and help- 
ful. A general discussion of the various 
classes of symptoms introduces each chap- 
ter, followed by causes of the particular 
symptoms in each disease. Theory occu- 
pies but a small place because the student 
of medicine should learn facts first. The 
various explanations are outlined, which 
renders the text more pleasing to the eye. 
It teaches the student to understand why 
many a symptom exists; he does not take 
everything for granted and is therefore the 

better able to use a remedy when indicated. 

Proceedings of the twenty-sixth annual 
convention of the National Funeral Di- 
rectors' Association of the United States. 
Held at Norfolk, Va., Oct. 8-10, 1907. 

Cosmetic Surgery. The correction of fea- 
' tural imperfections. By Charles C. Mil- 
ler, M. D. Including the description of 
a variety of operations for improving the 
appearance of the face. 136 pages. 73 
illustrations. Prepaid $1.50. Published 
by the Author, 70 State St., Chicago, 111. 
The author describes in a concise manner 
the various operations which he performs, 
under infiltration anesthesia, for the cor- 
rection of featural deformities. The il- 
lustrations are not specially attractive, yet 
they show what is intended clearly enough. 
The descriptions are short, concise and 

The Every-Day Diseases of Children and 

Their Rational Treatment. By Geo. H. 

Candler, M. D. The Clinic Pub. Co., 

Chicago, 1907. 

This little volume contains a vast fund 
of information for the student and for the 
every day practitioner. It includes those 
little things, details, which the large text 
books omit. The specialist knows these 
things or should know them because he has 
learned them by experience, but this book 
is not for him. The general practitioner 
however probably sees and is called upon 
to treat more of the ills of childhood and 
infancy than all thepediatrists put together. 
Alkaloidal Therapy forms the basis of the 
work . 


"My wife has that awful disease, klepto- 

"Is she trying to cure it?" 

"Well, she is taking something all the 

— February LippincoWs. 


It is clear they were made for each other; 

What else can a kind fate intend? 
For, just to the penny, his salary 

Is the limit of what she can spend. 

— February LippincotVs. 

Abstracts of the Leading articles 
of the month. 

Tubal Abortion.— Fitzgerald (Lancet) 
gives the history of one case. The patient 
was a primipara of thirty-five years, married 
nine years. For three years she had had 


leucorrhea. irregular menstruation, metror- lated end was found is uncommon, as is 
rhagia, and pain in the left side. In June, also such a degree of attenuation of the 
1907, shehad an attack of acute epigastric tube. The control of the hemorrhage was 
pain, and presented some evidences of inter- rendered doubly difficult by the fact that 
nal hemorrhage, but her menstruation had one had so limited an opening into the peri- 
been fairly normal, pulse was good, abdomi- toneal cavity through which to work, and 
nal palpation caused no pain, and exami- even this was more or less diminished by 
nation of the pelvis showed only a cervical the endeavors made to avoid damaging the 
polypus, a slightly enlarged uterus, and bowel. On subsequent consideration one 
some infiltration of the right broad ligament, cannot but regret that the original incision 
While in hospital for the proposed removal was not abandoned and an opening made, 
of the polyp, she was seized with sudden through skin and muscle, directly over the 
epigastric pain; apparently fainted and opening into the peritoneal cavity. It 
vomited much coffee-ground material. The would certainly have facilitated the opera- 
next day the polyp was removed, the uterus tion. The introduction and removal of the 
lightly curretted, and an exploratory incis- gauze — which was several yards long — 
ion made through the posterior fornix. The would have been simpler, especially the re- 
findings in the pelvis at once let to a diagno- moval. 
sis of ruptured extrauterine pregnancy and 

the abdomen was immediately opened." The A Case of Swine Erysipelas in Man Cured 

intestines were firmly matted by adhesions, by the Use of Serum.— Welzel, (Munch. Med. 

and entrance was finally gained to the ab- Woch.) says that several cases have been re- 

dominal cavity by stripping the peritoneum ported in which human beings, usually veter- 

from the muscular sheath and working inarians , have been infected with the bacilli 

down along the right of the incision. In 
this way access was gained to a small cav 

of swine erysipelas. In performing the un- 

ity and thence to a larger one lying lower munizations which are now done on a large 
down and which had been entered by the scale, the antiserum is injected into the ani- 
incision through the fornix. In this sec- mal and also a very small amount of a pure 
ond cavity was a large clot in the middle culture of the bacilli. In doing this it not 
of which was the amnion. The rest of the infref uent i v i iappens that the operator pricks 
tube was much elongated, exceedingly " , ' . . ,« . , ,. ,, 
friable, and formed a pedicle for the dilated ° r scratches bmself ' 0Wln S to the restlessness 
portion which lay to the right and slightly of the ammal - O f five cases o£ this sort re- 
above the level of the anterior, superior P ort ed one ended fatally and the ordinary sur 
iliac spine under cover of a closely matted gical measures applied did not appear to 
mass of intestines. The condition of the modify the course of the disease in the others. 
patient was now such that all that could be Another veterinarian who accidentally inocu- 
done was to pack hurriedly the cavities , * -, , • i* « ■ • , •, - ., 
„.;ti, nr«„,„ 'ri,^ * a \ "-* V1 - la ted himself promptly injected some of the 
with gauze. 1 he next day the packing . -,,,,, 
was removed and bleeding recommenced. immune serum > Wlth the result that the sympt- 
After a perilous experience the patient mos ( l lli( ' kl y subsided. Welzel 's own patient 
finally recovered. The operator notes that was :| veterinarian who inoculated himself in 
the difficulty in making a satisfactory diag- the course of his work and manifested sympt- 
nosis, previous to operation, was greatly ms of a severe infection that threatened to 
increased by the protracted historv the i r i . i • • « ,, 
persistent Regularity of the patient's men 'T'"" ^ U ' r ^' 1 A S1 ^ e m ' ectl0n of the 
struation, and the fact that though, as was ,m,mar - v immune serum used fOT treating pigs 
subsequently discovered, she had lost a suffleied lo arrest the infection and produced 
considerable amount of blood her pulse almosl instani relief in regard to both the 
throughoul was a normal one. Her pain and the local symptoms. 
anemic appearance, too, was regarded by 

her relatives as being her normal condition. R ena '- Decapsulation in Eclampsia, — Franck- 

Then, again, the absence of all pain or ten- Munchener mediziniche Wochenschrift, sum- 

derness during examination of the uterus marizes the histories of nine cases in which 

audits surroundings was a misleading fea- Edebohl's suggestion of renal decapsulation 

ture. I he presence of two cavities appears fm . ,.„, , ,.„„,„„, lt , , • , , 

to be explained by supposing that there had for the trea * meni " eclampsia has been car- 
been, at least, two serious hemorrhages. " :""' ''' ,ls the descrl Ption of a tenth 

With each hemorrhage the dilated tube, ( ' :1S( ' "' llis own - '" tllis instance the patient, 

which all the time appears to have been wllf > had passed into the status eclampticus 

endeavoring to expel the ovum, was push- and had seizures every ten minutes, did not 

ed higher up into the abdominal cavity and improve after accouchement force and fifteen 

elongated. I he position in which the di- hours later was practically moribund, with 


suppression of urine. Double decapslation gescent, and erectile. There is intraalveolar 

was dune withoul anesthesia and a diminution edema, the alveoli being distended with an 

,,, the attacks very promptly resulted, so that albuminous duid without fibrim. Symptoms 

during the succeeding twenty-four hours there are urgenl dyspnea, respiratory anguish, and 

were very few and twenty-four hours after pressure of crepitant and bubbling rales 

the operation they ceased entirely, the patient There is no modification of the respiratory 

became conscious, and a considerable amount rhythm, and no elevation of the temperature 

of urine with only a comparatively moderate is observed. Death occurs rapidly, often after 

albumin content was voided. The improve- more or less severe convulsions. The treat 

ment in the patient's condition was striking, ment of the condition is mainly prophylactic 

bul she died as the result of a bronchopneu- Sparteine and strophantus are often of con 

monia on the fourth day. The author consid- siderable value, but the authors say that the 

cis that while the mortality of the reported use of digitalis is strongly contraindicated. 

cases is about 30 per cent., this is in large Morphine is never admissible. Oxygen inhala- 

measure due to the fact that most of the pa- tions will sometimes be found to be of real 

tients were already in deseprate straits, and service. 

he believes that in cases in which the seizures Remarks on Appendix Abscess.— Battle, 

peisist after the uterus has been emptied, de- The Practitioner, says that a waiting policy i^ 

capsulation should immediately be resorted to not advisable for this condition, for a favor 

able termination can seldom be prognosticated 
Tubercle Bacilli Entering by Way oi the 

, with assurance. Manv dangers may be avoid- 
Intact Skin. — Mabcs has shown that the tuber- 

, , ed by the early evaucation of such an abscess, 

cle mav enter the body through the unbroken ,, ' ., . , ,, ,, ,, , 

- j & £ or ( |) lt ma y p en into tbe bladder, large 

skin, and that this may happen especially m . . ' , . . , , , ,, 

11 r bowel, or rectum; (2) it may extend to the 

the infant on account of its more tender skin. . 1 . „ . , „ . T , . , 

pelvis and left side oi the abdomen, or inn 
The entrance of the bacteria is favored by ,. , ,. . , ,, _, , 

the hepatic region or even into the pleural 
washing and shaving the skin, and a certain ^ ., m&y rupture .^ the peritonG;ll 

amount of dirt and scales upon the skin act ^..^ (4) . f may eauge general toxaemia . 
as a protector against their entrance. The (g) ^ m&y |)( eomplicated by intestinal ob 
germs pass directly to the nearest lymphatic gtruction stresg ig laid upon thfi importauce 
glands. Slight skin lesions m children and of ^^ exarainationj especially iu cases in 
eczema favor the entrance of the bacilli. Tu- wMch fche svmptoms are inde fl n ite and the 
berculosis which has thus reached the glands ^ ^ ^ ^ . g thought (hat remoyal of 
progress very slowly and is often found in the fhe appendix is not indicated as a routin0 
glands of the mediastinum and the bronchial p ,, u . ti( , e The opening . of thfl abgcesg ig witfc . 
glands at autopsy, without having given any Qut danger if done by & eompetent person . 
signs during life. Such children are called , )nt fchfl geardi for the appendix in tbe wal , 
scrofulous.— La Presse Medicale. of . m abgcegs may cause gerioug trouble . Th? 

Acute Pulmonary Edema— Mery an Badon- mortality of appendix abscess from all causes 
neix, Gazette des Hopitaux, say that acute in a consecutive series is placed at 10 per cent., 
pulmonary edema is always on active process but if treated surgically from the first it 
resulting from a sudden elevation of arterial should be under 5 per cent. 
tension in the pulmonary artery and char- Suppuration in the Region of the Pharynx, 
aeterized by a sudden effusion of serum into __ Fitzwilliams, The Practitioner, recalls the 
(he alveoli. It is distinguished from passive f ac t that this subject has attracted the atten- 
( -(ingestion by the suddenness of its onset and tion of many eminent writers.. He analyzes 
the severity of its results. It is essentially a series of seventy-five cases observed among 
noninflammatory. It results from affections children, and divides them into the following 
of the kidneys, and of the aorta, in gouty sub- groupes: 1. Quinsy or suppuration in and 
jeets. and in rheumatic conditions, as well as around the tonsil, the pus being always super- 
in some forms of intoxication. There is pres- ficial to the pharyngeal aponeurosis. 2. Ret- 
ent arterial edema, and an afflux of blood ropharyngeal abscess, in which the suppura- 
iavorcd by vasodilatation of the arterial sys- tion starts in the retropharyngeal space. The 
tern. Various theories are advanced as to its abyscess is outside the pharyngeal space. The 
causation; the angionemrotic and toxic are abscess is outside the pharyngeal walls, be- 
the principal ones. The lungs are rigid, tur- tween the buccopharyngeal aponeurosis and 


llj( . pi . e vertebral layer of Ibe deep cervical does uol bursl in Ibe bladder, necessitating a 
tasc i a . suppuration, which is perineal opening. 

between tbe lymphoid tissue in the mucous Gastric Conditions in Wasted Infants.— 

membrane and the pharyngeal aponeurosis Aljj]( , r and will( . oX) Lancet, suggest that in 

ppuration or caseation in the deep cer- baling w j,], was t e d infants we take advan- 

vical glands. tage of the modern methods of analysis of tbe 

Genitourinary Tuberculosis.— Godlee, Lan- gastlic con tents. As a result of their investi- 

osis in relation to treat- g . at j ons t hey jj n) j that differences exist in the 

mem of tuberculosis of the genitourinary or- ,,.,,,,,,. sec retion in infantile wasting, corres- 

... the most frequent form ,„ )li(i ; n ,, to three clinical groups, as follows: 

tuberculosis of the testicles, he has come to -,_ p ure marasmus or atrophic dyspepsia. As 

conclusions: 1. That it is usu- a resu i t f prematurity, immaturity, insuf- 

alfj a chronic disease and that a majority ol ,,,.;,, , lt ,„. i m p rop er feeding, etc., the infant 

which appear to be acute or sub- wasteSi There is a furred tongue, with a ten"- 

acute bave been preceded by a slow enlarge ,j enc y ,„ diarrhoea and vomiting, and progres- 

oftheorgan which hasescaiped tbe atten- siv(> was ti n g, with no gigns of any acute local 

tion of the patient. And this is based upon the ( jj sease . p os ( ra0 rtem no changes are found 

thai thickenings of the epididymis other than a t rop hy. Examination of the gas- 

often discovered accidentally, and tric con tents shows a diminished activity of 

in operations on the acute or sub- botlj ac y an) j f erme nt secreting glands, no 

acute uims more extensive cheesy retention of food in the stomach, and no 

ses ais usually met with than it is muc i n . o. Hypertrophic pyloric stensis. Most 

possible to suppose could have been formed usua ll v in a male child vomiting starts in the 

since the apparent onset of the disease. No first f ew W( . eks f nf e - the vomitus quickly 

doubl the acute process does occur, but it is becomes large in amount, forcible in charact- 

exceptional. 2. That it is so common as to efj ., ml j s accompanied by rapid wasting. Con- 

be almost the rule for the second testicle gtipation is usually marked, the stools being 

ultimately to be affected, whether the first sma n an( j mar blelike. The tongue is gener- 

bas been removed or not. Tbe writer has a lly very furred. The physical signs are de- 

given i » i > removing every tuberculous testicle fl n it e gastric peristalsis and a palpable pyloric 

however quiescent, if no sign of tbe presence tumor. The contents of the stomach show, as 

of tubercle could be found elsewhere, because a ru i ej a ma rked increase in the ferment 

it so often leads to disappointment, the pa- activity, together with excessive secretion of 

tient returning with the other testicle affected, mucin. There is also very obvious retention 

For tiie same reason he depreciates extensive f f 00(l i„ the stomach. The total acidity 

operations upon the vas deferens and vesicular varies, but tends to be below normal. After 

seminales. He does not hesitate, however, to regu lar gastric lavage has been carried out for 

remove on,, testicle which is completely dis a short period, the gastric contents lose their 

organized, both in bodj and epididymis, if it abnormalities. 3. Acid dyspepsia. Here the 

much pain or inconvenience, and symptoms tend to occur in children three 

i Mich circumstances takes away as much months of age or over. The vomiting is large 

vas as can easilj he got at. Thorough ;„ amount and may he rather projectile in 

lenl results. II' after orcbidectomy the other character and the bowels are constipated. Tim 

curetting of th< epididymis often gives excel- wasting is considerable, but less than in pylor 

lb' attches each compress or piece of gauze, i c stenosis. The tongue is clean, and the 

testicle is subsequently affected it should not abdomen is usually full. No true peristaltic 

!»;• removed, hut the obviously diseased por- waves are seen, nor is the pylorus palpable. 

tions should he cut an.... or scraped. The in- The gastric contents show an increase in their 

of quite a small portion of total acidity, the ferment activity being nor 

the organ in sufficient to ward off the unpleas- mal, or below normal. There is no mucin 

results oi' complete castration. A very con present, but there is obvious retention of food 

siderable deposit of tubercle may occur in the in the stomach, [n atrophic dyspepsia pepsin 

prostate without causing any symptoms what and acids should be given. In acid dyspepsia 

and the process go on to almost complete alkaline gastric lavage, together with the ad- 

atropy of the gland. Sometimes an abscess ministration of alkalies, such as bicarbonate, 

forms, causing retention of urine, and, if it or citrate of soda, are indicated. In pyloric 


stenosis the best diel is one of a noncoagiil- should be taken, and as the laceration lakes 

able nature, such as a whey aud cream mix- place only when the head is being drawn 

ture. The smallest practicable doses of food through it is possible while waiting in this 

should be given, so as to avoid setting up a stage of labor to prevent a laceration and yet 

fatal diarrhoea in the atrophied intestine. to protect the child from suffocation by hold- 

The Reaction of Bordet and Gengou in R. a - 
st>ect to the Streptococcus in Scarlet Fever.— 

ing his fingers so that the child can draw air 
into its lungs by respiration, or by introducing 

a catheter into its mouth. In central placenta 
Koi\ and Mallein, La Presse Medicale, state . , , , „ , , ,. , ., a , 

r ' ' praevia one should first try to displace the flap 

that without entering into a discussion as to . ... . «,,-,- „.;m> 

ot the placenta with the two ringers with 
the streptococcic nature of scarlet fever they ■ • , , e ,, u - j - i„ 

1 . . • whirh he performs the combined version, be- 

can give the following as • established facts: 
1. The serum of persons with scarlet fever 
contains antibodies to the strepococcus, anti- 
bodies which they have found ten times out of 
twelve by means of the reaction of Bordet and 

cause this procedure is less injurious to the 
meshes of the wire basket and tied together, 
child than boring through the placenta. When 
this cannot be done the placenta can be per- 
forated at any time, and as hardly a child 
Gengou. 2. They have found this to be the ,, , . ' . , , . 

survives there is no object then in hastening 

case as early as the fourth day, and as late as 
the thirty-eighth day. 3. The reaction of 
Bordet fails in regard to the streptococcus in 

the delivery. Very often in placenta praevia 
the question is that of miscarriage, and then 
no active treatment should be undertaken, be- 

the other streptococcic conditions. 4. It re- ^^ ^ offerg ^ hope of ^ m& of ^ 

mams to be established whether this is a sep- ^ an<J ig m(we dangerous to the motbe , 

cific reaction to the streptococcus of scarlet The author depreeates the performance of 

fever, or a reaction common to all or to many • ,, i i • i • i /-. i- 

J either abdominal or vaginal Caesarean section 
species of streptococci. 5. This reaction may h) thege easeg> 

be utilized as serodiagnostic. 

Mucocele of the Acesscry Nasal Sinuses — ■ 
Dangers and Treatment of Placenta Prae- Turner, The Edinburgh Medical Journal, ad- 
Via.— Zweifel, Munchener Medizinische Woch- VOC ates from his experience the establishment 
enschrift, thus summarizes the principal in- f a i arge opening between the sinus and the 
dications for treatment. Every severe haem- nasa i eav ity. In the nine cases in which this 
orrbage in the second half of pregnancy which procedure was carried out, cure resulted in all 
suggests the thought of placenta praevia f them with a minimum of disfigurement. As 
should be so treated, because of the very great a preliminary step the middle turbinated bone 
danger that a second haemorrhage may cost 1S removed in some of them. An incision is 
the life of the mother. To do this the woman then made parallel to and beneath the eye- 
should be tamponed for some time, at least brow, which is left unshaved; the upper eye- 
a week, unless the birth takes place in a less ]j ( i j s detached and turned downward. After 
time. For a long continued tamponade noth- the contents of the mucocele have been re- 
ing can take the place of the colpeurynter. All moved, any portion of the floor of the frontal 
material used for the tamponade must be s i nuSj or f the outer wall of the ethmoidal 
aseptic. The best method to induce labor is labyrinth, which has not already been absorb- 
the artificial rupture of the amnion, but this e d. is removed. In some of the cases a small 
can be performed only in cases in which the area of the anterior wall of the frontal sinus 
membrane bulges forward, and this is rarely is also removed. The lining membrane of the 
the case in placenta praevia. As a rule the cavity is left untouched. The communication 
haemorrhage is checked most cretainly, and with the nasal cavity is then sought for with 
with (he best maintenance of asepsis by ver- a fine probe; no ostium may be found. Wheth- 
sion performed as soon as possible, by tha er the normal ostium be found or not, a large 
combined method of Braxton Hicks when the opening into the nose is made by means of 
cervix is faultily dilated. Extraction should burrs, and through this a rubber drainage tube 
no! follow until the crevix is nearly or quite is passed, being held in position in the lowest 
dilated on account of the danger of lacerations part of the sinus by a collar formed by turn- 
of the cervix. At the same time* this delay ing over its upper end. The lower end of the 
adds lo the danger of the child and should not tube does not quite reach the vestibule of the 
! " perisited in to its detriment. Where a nose. The sinus is next lightly packed with 
laceration is not to be feared active procedures gauze, the end of which is brought out through 


the inner 


with Hie 


gauze is 


,£ the incision which is sutured is thickly coated and the patient eannot take 

„, ,f this small area. The milk, give broths, whey, or rice water for a 

• ( .,l .„ the end of tour or live few days. Alcohol will not help the dysentery 
ty is washed out, and if the nasal and is bad for the liver. All food should be 
e tube is found to be working satis- given tepid. Castor oil, sulphate of magnesia, 
factorilv the skin incision is allowed to close or calomel should be give first to clear out the 
in a w,',.k or ten days. The bandage is then bowel. Small enemata of saline solution will 
removed, and the patient can be instructed to diminish tenesmus, and cocaine or opium sup- 
wash out the sinus daily by introducing the positories may be given for the same purpose, 
line nozzle of a syringe into the nasal end of Where the,,, is much haemarrhage from the 
inage tube. The success of the opera- bowels, an ice bag should be placed over the 
tion will largely depend upon the maintenance abdomen and opium given internally. For col- 
of a permanent opening Let ween the sinus and lapse the subcutaneous injection of normal 
l he nose, therefore it is necessary to keep the saline soloution is of service. Ipecac and 
drainage tube in position for a considerable large enemata of silver nitrate are not useful 
lime. It should not be removed until at least in the acute cases. Serum treatment, which 
six weeks after the operation. is bactericidal as well as antitoxic, is of great 
Dysentery - Sandwith, (Lancet) states ™ lu « ™ early cases (second or third day), the 
thai the diagnosis of dysentery is not difflcut blood and mucus disappenng, the pain and 
to physicians trained in the 'examination of tenesmus ceasing, and the patient getting re 

the excreta. The disease most often confound- fresbin S slee P" In mild cases olll >' one in J ec '- 

, • i tion of ten cubic centimetres is given; in se- 

ed witii dysentery are carcinoma, polypi, and & ' 

, .,. ',. , , , • , i ■ verer cases this is repeated after six to ten 

syphilis id the rectum, haemorrhoids, and, in l 

those returning from the tropics, bilharziosis. hours ' and in 8 Tave cases the in J e <*i™ s *ust 
Bacillary dysentery can be distinguished from be re P eated twlce dai ^ for two or three da > s " 
amoebic dysentery. The following point, Amoebic d y se »tery is the *>»n niet ™th so 
should he remembered: 1. Amoebic dysen- fl Wently in the tropics, and in London m 
tery, unless skillfully treated at (he begining, peven iuw * as frec t uent as the bacilli >' form ' 
usually runs a chrome course, while the bacil The symptoms of liver abscesses are some- 
lary lasts onlv from four to eight days in mild times lhe first to attract attention to the in- 
cases, and from three to six weeks in the < enthral disease. The general treatment is the 
serious ones. 2. In the amoebic form no Same as hat of the aeute bacilla ^ ^im; rest 
bacilli can be found unless there is, as is rare, useful dru § b ~ v the mouth as a continuance; 
bui quite possible, a mixed infection of both is especially necessary. Bismuth is the most 
amoebic and bacillary dysentery. 3. Tox i tbe salicylate in wafers of fifteen grains every 
symptoms, such as high fever, rapid emancia- £our hours ,s to be P referred - The ^ional 
ion, and nerve complications, exist in bacillary treatmen1 1S to destr °y tbe amoebae by means 
dysentery, but no! usually in the amoebic ° f rectal ir «g ati °ns. Quinine (1 to 1,000), 
no,,,. I. Liver abscess is a very frequent com- nitrate of silver (1 to 1 ' 000 )' and sul P hate o£ 

plication of amoebic dysentery, and does not 
exist iii the unmixed bacillary form. The con- 
ditions necessary for a certain diagnosis of 
bacillary dysentery are the positive agglutin 

pper (1 to 1,000) are all useful. Tbe 
enemata need nol be retained more than five 
minutes, and should be given warm. Once a 
da\ is usualh suffisisnt a simple cl< isnsn . 

ati actions of the dysentery bacillus with enema bexng glven al ni - h1 - U is impossible 

the hi i serum of the patient, or the isola- '" pr ° duCe :! vaccine for the amoebi< ' l '" n11 ;,i " 

li f the bacillus from the faeces of 11: ■ '^e"' er.v, because there is no evidence of any 

patient ,„• from the organs after death Th- ereatl0n "' toxme - The writer does not think 

bacilli are obtai I more readily and in lamer '""'"^ ° f the surgical treatment of dysentery, 

numbers from the mucous membrane of the consisting in colostomy, or in washing out the 
rectum than from the stools. They do not bowe l tbro "S:h the appendix. 
enter the general circulation. The treatment The Prognosis in Operation for Vulvar Car- 
°f tbi acute form calls for rest in bed as the cinama.— Grunbaum (Deutsch. med. Woch.) 
intial. Physiological rest for the in- records five cases from Landau's clinic in Ber- 
testines should be obtained by stopping all lin to show that the outlook is not as black 
solid food, and giving small quantities of milk as was painted by Hildebrandt in 1S70, when 
every two or three hours. When the tongu? he stated that no permanent result could bo 


expected of there was any involvement of the when the throal is red and swollen, porridge, 
inguinal glands. The results in these cas^s broths and eggs may be given, and later. 
of the Landau's clinic were very encouraging, meats, fish, vegetable purees, eggs and bread, 
Tn one ease of advanced carcinoma recurrence all unsalted. Diuretics are administered as a 
look place in a very short time and led to the matter of routine. A series of cases success- 
death of the patient, and in another, where fully treated according to this regime are cited 
operation had been advised long before the by the author. 

patient would consent, death occurred one and 
[uarters years after operation. Of the 

The Time of Leaving Bed After Normal 

... • A « nn Labor. — Bouchacourt (Presse Medicale) re- 

>ther three eases, one patient remained free _ > 

, , ... , ,, views the disadvantages and advantages of 

or live and a halt years, when a small recur- s & 

,, -, , , , ,. n the puerperal woman leaving (he bed early 

a the sear was removed, but she lived ' J . 

after a normal iabor. The dangers in the 

main are infection, arrest of involution of the 

litems, danger of uterine displacement, of 


for nine and a half years after the first opera- 
it on, and died of general debility at 82 years 

of age, though there was then another small 

"„,, ,, ,. . . -, embolism, and tinallv the danger of ptosis 

recurrence. The other two patients remained j s f 

n ,,„-,., , ,. , Onlv the last mentioned reallv need be con- 

six and a half and eight years, respectively. 

... „ ,, ,. , . siderod. All the authors who recommend leav- 

without return of the disease, and in one case 

,. . . ,, , , , ,, , ,, ing the bed earlv insist upon the use of a 

this was especially remarkable in that the ° J x 

, , „ -, , , . , , proper abdominal bandage. Infection can be 

glands were found to be carcinomatous when l 1 ° 

, , ,, ,. avoided. Earlv leaving of the childbed, in- 

removed at the operation. , 

^,, , ,. ,. , -j n i xi deed, seems to hasten the involution of the 

Other statistics are also considered by the 

., ■ ii .i iii ■ o -mn uteius, and to lessen the danger of a displace- 

author, especially the valuable series of 169 r 

,,,,', „ , -, ,- .,, , T , ment. Of course, sudden movements may lead 

eases collected by Coldschmidt (Inaugural ' J 

... ... T • '• -mno\ j hi to embolism, but Kuestner, in his very exten- 

Dissertation, Leipzig, 1902), and as a result he J 

D -, ,, . i i i <! sive experimental researches, did not meet 

finds that a permanent cure mav be hoped tor . ' 

, . in -n .i with a single instance of embolism. Among 

in a certain number of cases, even if there are 

, 3 , , . ,, -iiii, the advantages of a short stay in bed are a 

aleardv mestastases in the inguinal glands, but , . . Z. '. 

, , , , . ,, , ,, . , favorable influence upon digestion, circulation 

in order to obtain the best results a wide ex- , . „ . 

• •„,,. ,, , , , and urinary function, and the promotion of 

eision (d the primary growth must be made •. ^ 

i i.i ■ i , -i -, -,. „ ., milk secretion. 

and the niqiunal glands and surrounding fatty , • n . 

, i . , • i ix, 1 lie writer advises considerable freedom of 

tissues removed on both sides, whether or not . . 

, , , , , , movement while the woman is in bed. Gvm- 

an) enlargement can bo detected. 

nasties and passive movements are ad- 
A Salt Free Dietary in the Treatment of , , ,, m, , ., „ , 

vised bv some authors. The length of stav m 
Scarlet Fever and Acute Nephritis. — Delearde , -, , ,-, , ., , , ,, , , , 

* bed should be suited to the character and so- 

(L Echo Medical du Nord,) says that salt in • i j .- » ., j ,, ., e 

" • cial station of the patient and the gravity of 

small quantities has been often shown to be fte frQm Qne . q ^ ^^ ^ 

indispensable to the health of the normal body, fident in norma] caseg _ 

but in the way it is ordinarily employed (as 

a condiment) it passes as waste product Goitre and Cardiac Diseases. — Gittermann 
through the urine and feces. Most articles of (Berliner kliniche Woehenschrift) found 
diet contain in themselves a sufficient quantity among 895 patients with myogenous disease 
of salt. If the kidneys become affected and of the heart (651 men, 214 women) 121 with 
their activity diminished, excess salt is stored evident goitre (21 men, 100 women) in 11. 
in the tissues, which then call for water as a exophthalmic goitre was present; in 110 there 
solvent, thus causing edema. was a goitre which had lasted many years and 

While milk diet is not to be wholly con- to which in the course of time a disease of the 
demned, the writer calls attention to the fact muscle had been added. While in the cases 
that m giving a sufficient quantity to keep up of exophthalmic goitre the disease had begun 
nut ril ion, a considerable amount of salt is in- in early life, of the others 6 had begun to suf- 
gested, which may act as an irritant to the fer between the ages of twenty and thirty. 
kidneys, and, furthermore, milk is not regard- 19 between thirty and forty, 27 between forty 
ed as sufficiently sustaining during the period and fifty, 43 between fifty and sixty, and 15 
<>f convalescence in scarlet fever when the pa- over sixty. In 71 there was a myocarditis 
tienf should be fortified against the ravages with concentric hypertrophy of the heart, with 
03 secondary infection. During the stage no signs of Basedow's disease; in 29 there was 


arrhythmia without great acceleration; in 7 should continue to suppurate. 4. Finally he 

attacks of tachycardia, with otherwise normal recommends that the antitoxic miction should 

action „,• the heart. In S cases there were be made in every case in which the practition 

evident signs of arteriosclerosis; in 15 cardiac er has the least doubt. 

murmurs could be heard; 3 had valvnla. ^ Genesis of Albuminuria.— Schmidt, 

trouble due to rheumatism; 1 severe arthritis Munchener medizinische Woehenschrift, re- 

deformans, and in 1 there was great emacia ^ ^ ^ ^ ^ [t . g generally considere d 

. ,, the use of thyreoidin. Twelve pa 

that the albumin contained in nephritic urine 

tients bad tainting spells, 4 had serious steno- emanates from ||u , ,,,„„,,_ It is assumed that 

cardie attacks with pulmonary oedema; only inflammatory ehanges in the kidneys interfeve 

three time were slight circulatory disturbances ^ ^ ^ q£ ^ renal ^ and per 

and lma found - Tn 31 tllere ™ Simp i e mit serum albumin to pass through and emerge 

dilatation of the hear, ; 23 of these had tremb- ^ ^ some q£ ^ formed d ... 

ling of the hands and general nervous sympt- 

ments are considered as being or renal origin 

oms, with rheumatim pains, and S had a slight ^^ ^^ ^ ^ ^ ^ ^ be 
exophthalmos. Five had heart murmurs 13 a]tn „. ( , (|i(M . accurate and that perhaps all or al . 

had acceleration of the pulse, usually regular. 

most all of the albumin comes from the renal 

and 18 had attacks of tachycardia. Many . ., ,, T7 , ,, , . , 

J . parenchyma itself. He points out that just 

more symptoms are likewise mentioned. ■' a ■, * i ai 

1 as any inflamed organ, for example, the serous 

Haemolysis Through, Serpent Venom. — Von membranes or the epidermis deprived of the 

Dungern and (oca. Muenchener Medizinische cutis, may pour out albuminous exudate, sc 

Woehenschrift. say that the peculiar appear- the inflamed kidney may be the seat of an 

ances which we have learned to recognize with albuminous exudation which will be the richer 

cobralecithin haoemlysis can also be produced in albumin the fresher, the more intense, and 

by an entirely different mechanism, as when the more extensive the pathological process is. 

it is caused in the blood solution by immune This exudate may therefore be considered as 8 

bodies and complement. They recount a con- sort of wound secretion from the kidney. The 

siderable number of experiments and draw the point is of more than theoretical interest, for 

conclusion that the antitoxine produced by. the albumin in physiological, or orthostatic 

immunization acts against the native cobra almuminuria would probably not have this 

poison contained in the haemolysin alone, but origin, and by the development of appropriate 

not against the finished cobralecithin haemo. tests it might be possible to evolve differential 

lysin. They also say that they have obtained diagnostic measures founded on this principle. 

from various ovolecithin preparations without 

, , , ,. , . ,. , , The Action of Pancreatin in Carcinoma.-- 
cobra venom a naemolytic substance •which be- 

, ,, -. ,. , , Hoffman, Munchener medizinische Wocheu- 

liaves the same as regards proportionate soln- 

, •,-. , i i i ii t schrift, studied the effect of this ferment on a 

Inlity in water, alcohol, ether, and acetone, as * 

, i , i • -hi • carcinomatous new growth of the external 

the baemolysm with cobra poison. 

auditory meatus occurring in a woman of 

When and How Should an Injection of An- sixty-eight years. Sections of the tumor show- 
titanic Serum be Given? — Hardouin, LaPresse ed that it was a carcinoma, and it recurred 
Medicale, answers this question thus: 1 In after operation, finally becoming inoperable 
everj case where, on account of a tortuous Pancreatin was applied locally and the ulcer- 
wound, one is not certain of his ability to ob- ating surafce became clean, the pain and hem- 
tain a rigorous disinfection, particularly when orrhage ceased, and the growth became small- 
the patient has been specially exposed to con- er. The action of the ferment was later re- 
lamination. 'J. This injection should he mad" stricted through the fact that epidermization 
- soon as possible after the accident, but if look place over a large portion o fthe growth 
one ]< called to a patient with a suppurating This new formed skin was purposely not re- 
tortuous wound forty-eight hours or three moved mechanically, as it was desired to study 
days after the accident the same injection < lie effect of the pancreatin alone. The patient 
should be made, because, even if the effect up- died suddenly, apparently of embolism, with 
on the toxines is not so great, less cells will be out any meningeal symptoms. Examination of 
destroyed. 3. The injection of the antitetanic the tumor tissue showed extreme edematous 
serum should be repeated two or three times infiltration and moderate cellular growth of 
at an interval of eight days if the wound the connective tissue. The capillary endothe- 


lium was swollen and there were the evidences orifice; in women, on the contrary, it is in the 
of deep-seated degenration, but whether these anterior part of the anus. They may be con- 
were the result of the action of the pancreatin fined to the mucous membrane, but are some- 
or not is uncertain. The lesions resembled those times prolonged to the skin around the anus, 
of erysipelas and the author suggests that the In the latter case, the integuments form a lit 
effects of this disease, the cautery, and in part tie projection at the level of the fissure, which 
the Rontgen rays may act on carcinomatous is often mistaken for haemorrhoid. Having 
lesions in somewhat the same way as the pan- located the ulcer, an application is made to 
creatin. He also suggests that pyocyanase, on the surface of saturated solution of potas- 
aecount of its proteolytic and bactericidal sium permanganate by means of a small piece 
properites, my be found of use in the treat- of cotton, tightly wound around a probe. If 
menl of inoperable cancers. should be applied to the whole extent of the 

, . _ , , . „ fissure, but care should be taken that there 

The Results Obtained in Tuberculosis Sana- . , . . „ , . , _ ,. 

should be no excess of caustic to overflow the 
of statistics relative to the results obtained bv ,. ,. . „ , . 

. " adjacent tissues. All the fissures are thu> 
AVoehenschrift. presents an exhaustive series , , , , .... , , 

■ treated at one sitting, each having onlv one 
toria. — Croissant, Munchener medizimschs ,. ,. m , . , , , ., 

application. This treatment can be repeater! 
an acceleration of the pulse with arrhythmia: 1 ., ... . , , ........ 

? , dailv, until cure is complete, which will be in 

(he sanatorium treatment of tuberculous pa „ , , , , . ' T . 

c from eleven to twentv-eight seances. — Journal 
fients in various stages of the disease as com- -, , ■ j t» • 

& . tie medecme de Paris. 

pared with (hose obtained outside of institu- 
tions. AA'hile the results of this analysis are Extract Mistletoe for Haemorrhage.— Gaul- 
uof particularly favorable to the institutions, tier (Le Bulletin medical) reports the results 
the author considers that the spirit of pessim- obtained by t lie administration of an aqueous 
ism that lias lately made itself felt in this con- extract of mistletoe of the oak, and also by 
Election is not justified, even though it is un- hypodermatic injection. The usual dose of 
likely that sanatorium statistics will ever be the extract in pill form was 0.20 to 0.30 
able to present results imposing from tli3 gramme (or gr. iii to v) in the twenty-four 
numerical aspect. The greatest good is hours. The hypodermatic dose was 1 c.c. <>f 
achieved not in point of numbers, but in indi- a solution representing 0.20 gramme of the 
vidual cases, and this is not evident from aqueous extract. The physiological action i= 
statistics. In the earlier stages but little that of a reducer of tension, a kypotensor. 
more is accomplished within the institution.-; tts clinical applications are found in conges- 
fhan outside and therefore it is hardly nee- tive haemorrhages and partly the haemoptyses 
essary to set the standard for admission ^o of tuberculosis, which it stops almost imme- 
these so high. More advanced cases must be diately, by reducing arterial pressure. It is 
kept long enough to effect a real cure, longer also valuable in relieving the symptoms aris- 
than is usually the case, and such patients m S in arteriosclerosis, by reducing the high 
when discharged serve as a very potent means tension, without producing toxic effects. Qth- 
of education and prophylaxis among the mass- er applications of a similar character may be 
es. A point of the greatest importance is to found for this antihaemorrhagic and hypo- 
improve the social condition of the poorer tensive remedy. 

classes in regard to dwellings and mode of 

jj£ e Hemophilia Transmitted Through the Male 

— Swanton (Lancet) reports an interesting 

Potassium Permanganate Solution for Fis- family history. The disease originally ap- 

sure of the Anus. — Schuls, a Russian physi- peared de novo in the father. Of his thirteen 

cian, recommends the following simple treat- children the malady appeared in only one, a 

ment of lineal ulcer of the anus. He com son, who had been a bleeder from infancy. 

mences by placing the patient upon a diet This son, now a man of forty years, is the 

which will make soft stools. This being ac father of six girls and one boy, ranging from 

eomplished, he places the patient in the genu- two months to nineteen years, all of whom. 

pectorial position, and asks the patient to with the exception of one girl of eight years, 

make the rectal mucosa project. By separat- have shown haemophilic tendencies. Four 

ing the folds of this with the fingers, the fis have died, two boys at eight months and four 

sine is easily delected. Tn men the lesion is years respectively, from "convulsions," said 

usually found at the posterior path of the anal to have been due to epistaxis, and one boy. 


aged ten months, and a girl aged two years internal secretions of the ductless glands, es- 
and eigh t months from pneumonia following pecially the thyroid. Persons and animals de- 
measles accompanied by severe epistaxis and prived of i1 suffer from all sorts of infection 
blee ding from the mouth. The disease in the He then goes on to show that Graves' disease 
,,„,„.,. ehi( g e form of spontaneous and fever have similar clinical manifestations 
epistaxis v BScull to control and in as rapid pulse, thirst, sensation or heat; aftei 
preceeded by malaise and headache. He also awhile abundant perspiration, etc. Vasodils- 
suffers from painful swelling of his large tation and sweating can be produced by thy- 
joints Ml the children look healthy; they roid feeding. This latter symptom of fever is 
have verv soft while skin and fair hair. The a device of nature for eliminating toxic ma- 
only surviving sun suffers frequently from terials. Its occurrence is generally followed 
epistaxis, which is must alarming in its per- by an improvement in the general conditio! 
sistence. It is preceded, for a few days, by The diarrhea of some infectious diseases is a 
an elevated temperature with frontal head- typical Graves' symptom. To complete th,> 
tness, loss of appetite, and pain in analogy, the author mentions also toxic de- 
the back. The elbows, wrists, knees and composition of proteins, loss of weight, mus 
ankles are swollen and very painful. With eular weakness and fever, and increased urea 
the onset of bleeding he perspires freely. Any elimination. In both there is increased 
lorn, of traumatic bleeding is only controlled exidation, possible delirium, cutaneous 
with the greatest difficulty. He also bleed? eruptions, etc. Fever symptoms, there 
per anum when suffering from diarrhea. fore are due in a general way to increased 

activity. Consequently, it seems to the author 

Methylene Blue for Cracked Nipples.-- thai we are justified in believing that fever is 

[)resch (Gazette medicale de Paris) slates that a beneficienl institution of our organism which 

for several years he has employed a 3 pei is produced by an increased activity of the 

rent, solution of methylene blue ( Methyl! hi- thyroid gland as a reaction against toxic pro- 

oninae byroehloridum, Q. S. P.) as a topical duels and poisons in general. The symptoms 

application to the nipples, during nursing, in of fever are the expression of this increased 

order to prevent and cure fissures or excori.i- activity, and they are directed towards the 

tions. The results are alleged to be excellent; elimination of noxious elements. It would bo 

the method is convenient, economical, and does unreasonable to oppose this spontaneous heal- 

iquire any precautions as to nursing. The ing tendency of nature by fighting these salu- 

procedure is as follows: Both the nipples and tary symptoms, unless there be hyperpyrexia, 
tl e month of the child are washed with a 
warm solution of sodium bicarbonate (2 per 
cent.) Then, with a piece of absorbent cotton 
on a probe, the solution of methylene blue is 

to be applied to the nipples. This is best done s, ' ,,,, ' >' ,,;u ' s i, -° h > Rivalta ' wMch is ^tended 

immediately after nursing, when the nipples ^ aid m determining whether or not an effusion 

an. a, the maximum of erectility. The methy- 1S "'' t nflamma tory ™ture or « *»Mx a tram 

lene blue has a local anaesthetic effect, and sudate - In order to P erform xt a dro P of " 10 

also is an agent thai is very favorable to lh!) " l " Mucstn.n ,s allowed to fall into a solu 

keratinisation, the latter being of considerable """ of two drops "'' glacial acetic acid in 10 ° 

importance in an organ which is constantly e ' c - of water " [nstead of §' lacial acetic 20 

hen. macerated with saliva and the milk The ,ll '" |,s of ordl » ar y vine S ar ^ay be used. If 

infanl nurses from the nipples wilhout show lll( ' fluid is a " exudate the P ath of the dro P 

ing inconvenience or the slightest disgust. Its toward ""' bottom of the vesSel wU1 be mark " 

mouth becomes discolored with the blue slain ( "' by a white or bluish white steak of P reci " 

bu1 the urine is not sufficiently discolored to i, " : " 1 " 1 albummous material, while if it is a 

slain the napkins, although it innv contain transudate the :1( ' ( ' ti( ' acid solution remains 

traces, but this is of no importance. Daily clear ' Effusions taken from cadavers always 

applications for a * e et ,„■ ten days usually give S ne g ativ e result, bul this is unimportant, 

suffices fo effect I he cure ;iS ,lu ' lrn "' "'' lil( ' character of the process 

can usually be determined by inspection. 

Clinical Observations on the Origin of Fever Traces of 1)1 1 do not interfere with the re- 

Lorand (Lancet) declares thai the mainten suits and do not give any precipitate in the 

ance of health depends on the integrity of the case of transudates. The test is negative with 

The Differentiation of Transudates from 
Exudates. — Janowski, Berliner klinische 
Wochenschrift,, refers to a test suggested 



normal cerebrospinal fluid, the fluid from wire basket in which they are sterilized. Only 

eehinococcus cysts of the liver, hydronephrosis free ends of the tapes are passed through the 

and amniotic fluid. It is positive with fluid used after the abdomen is opened, to the 

from incarcerated hernias, ovarian cysts, and are used, and to each compress is attched a 

hydrocele children. In a large number of large compresses of several layers of gauze 

cases in which the methods was tested by the piece of narrow tape, over six feet long. The 

author it gave uniformly reliable results and The basket may be placed on the floor under 

in some instances gave decisive information the table. The tapes are not annoying after 

when the other data were inconclusive. Rivalta one is used to them. 

at first believed that the reaction was due to Breast Treatment — After Treatment. -- 

the presence of nucleoalbumin from the leuco- Ewald (Centralblatt fur Chirurgie) recom- 

cvtes occurring in inflammatory exudates, but mendst lie hollowing dressing, to avoid the 

in a later communication has expressed the stiffness of the shoulder, which prevents the 

view that it is caused by euglobulin and pseu- arm from being raised, after amputation of 

doglobulin from the blood. the breast. 

., „ „ , , After dressing the wound as usual, but with 

Acute Poisoning After Oil Enemas.— Butter ° ' 

n . . . , _ , . ... the arm free, the patient is put to bed and 

sack, Deutsche medizinische Wochenschnft : „,,.,.,,,, , 

. the hand ot the affected side is folded around 

reports a case of serious poisoning accompam- .-in t -i i u i ■> u 

1 . r . a short stick of wood, and held closed by a 

ed bv methemoglobinemia occurring in a wo- , . _, . . . , n .■,■,. 

„ , . ,, , . bandage. The band is then attached to a sup- 
man of thirty-three years, who was given an , „ ,, 

. port which extends out from the head or trie 

enema of 250 c.c. of oil of sesame for an at- , , . . , 

, , bed, so that the arm is about horizontal, and 

tack of gallstone colic. This remedy had been ™ ,, , 

, , „ „ , J ,.,. the forearm bent up. The elbow is support- 
frequently used before for the same condition . ... , „, 

1 ■ ed bv a plaster strip around the support. The 

without any untoward consequences, but on ... ,, ,,, . ,, 

. . .' position exercises traction on the fold of the 

the occasion m question the injection of the ... ... .. ,. - ,, , 

, J „ axilla and thus prevents the collecting of blood 

oil was promptlv followed bv symptoms of . ,. , „. . , „, ,.,, „ ,, 

. . ' m the wound. The arm is left still for three 

collapse which in a few hours became so severe . " . ,. , , „ „ , 

davs, and is then lowered for a tew minutes 

as to make recovery seem doubtful. The blood . ..... . , .,, , , 

at a time until it can be moved without danger 

was chocolate-colored and save the character- „ . ,, , ,, T . ,, ,. , . 

ot opening the wound. When the patient rises 

istic methemoLvlobin spectrum, while the sur- ,, . „ , ,, , i i -i i • 

the arm is fixed across the body while she is 

face of the bodv was cyanotic and cold , , . *, , 

■ up, and suspended as soon as she returns to 

especially the face, ears, fingers and toes. , . m , , . , , , „ , 

\ ■ bed. The dressing has not been found espec- 

I'rine passed ten hours after the enema con- . ,, „ , ,, , ,, , 

1 mllv uncomfortable, and the arm can be rais- 

tained blood cells and traces of albumin, but i ', ,, i -i ± m. ±1 j 

' ed to the head at any time after the dressing 

no hemoglobin or methemoglobin. Twelve , , , „ -, ... « , , , 

has not been found especially uncomfortable 

Inmrs later hemoglobin was present in abun- -, ,, , • , . ,i , ■, . 

1 and the arm can be raised to the head at any 

dance. The treatment consisted in the admin- ,- „, ,, n , 

time after the dressing is removed. 

ist ration of cardiac stimulants and in the in- _ _ . 

, . . . „ ... , , . Placenta Previa — Treatment in Private 

halation ot oxygen, which seemed to be par- . ,_ ^ „ , n , , 

• , , , ' . . m , ,. , „ ,, Practice. — Fueth (Centralblatt fur Gynakolo- 

ticularlv beneficial. The patient finally re- . ,..,.,.,. ' 

. , , , _, ... „ ,, .-, gie) recommends immediate delivery after the 

covered completely. Examination of the oil '" , , 

, , - ., „ ,■,,,,, . . ., „ first hemorrhage, as thert is great danger of 

revealed the fact that tins was not oil of se- , , , ,..„..,. 

, , .. „ .. _ . secondarv hemorrhage or septic infection with 

same, but a yellow paraffin oil. Several some- xl * , _ , , ' ., .. , 

, , . ., , , , , . other methods ot treatment, unless the patient 

what similar cases have been reported in , , , , ,. , ,.,,,. 

,.,....„ , ,, can be watched continuously until delivery. 

which the oil of sesame used was the oleum mn ,. , .,., , . . 

... . , . . „ . . The liability to placenta previa bears no re- 

sesann gallicnm instead of the oleum sesami , . , ' . ,, ., L ., 

, . ,. ,, , lation to the aa'e of the mother nor to the 

germanicum, and m these the symptoms , x . m . „ A 

, ,, ,, ,.,..-,', , number ot previous conceptions. The first 

strongly resemble those exhibited bv thp , „ , „ 

,, , .. hemorrhage usually occurs some time before 
author s patient. 

labor, and it is apt to recur if left to nature. 

Compresses Left in the Abdomen — Preven- Of the cases without immediato medical aid, 

tion.— Wechsberg (Centralblatt fur Gynako- one-third die. Of 726 cases only 23 had no 

logic) claims that no method of counting hemorrhage before labor pains occurred. 

or other means of accounting for compresses Treatment with tampons gives great danger 

is certain to guard against error as long as of infection in private work, and also of repe- 

ii are human. tition of the bleeding when no physician is 


:lt hand. I! i> therefore best to induce labor, material of approved quality is an essential. 
preferably by introduction and inflation of a and two pills should always be given at an 
metreurynter, as soon as the diagnosis can b3 interval of about five minutes. Under these 
made In hospital practice, where physicians conditions a negative result is more dependable 

arc always at hand, it is perhaps safe to wait than in the ease of the test meal and is almost 
of the bleeding is not profuse or can be check- as reliable as with the Schmidt diet. Positive 
ed without difficulty. results must be accepted with more caution. 

It is very well adapted for use as a method 
The Technique and Significance of Wasser- '"' rapid orientation and for repeated appli- 
man's Syphilis Reaction.— Meter, Berliner cation in watching the patient's progress. 
klinische Wochenschrift, describes the latest 

modifications in technique that are now used in Twenty-five Conservative Cesarean Opera- 
Wasserman's laboratory and also gives the tj ons without Maternal Mortality.— Canton 
results of the application of the method in a describes a series of twenty-Jive conservative 
considerable number of clinical cases. Three cesarean sections done without a single ma- 
hundred and fourteen serums, twenty-nine ternal death, and gives his conclusions from 
cerebrospinal fluids, one placenta, and one this experience. The conservative cesarean 
hydrocele fluid were examined. Of the 1S1 section is no longer a fearful operation, but, 
patients known to be syphilitic 81.7 per cent, thanks to antisepsis, every such operation les- 
gave a positive reaction, 2.7 per cent, a doubt- sens death from labor. In contracted 
t ul reaction, and 15.6 per cent, a negative pelves when the diameter is less 

reaction, [n 21 cases in which syphilis could than seven centimers and ahall, with 
be excluded the result was always negative. a living infant of normal development, 
The author concludes that the test is specific the cesarean section is absolutely indi- 
for syphilis and that itis sufficiently reliable cated. In contractions with diameter of more 
to afford a useful addition to our diagnostic than seven and a half centimeters, with a 
mands a skillful and experienced worker for living normally developed child, cesarean see- 
methods, but that its complicated nature de- tion should be done whenever the disproportion 
its performance. between the diameters of the head and the 

elvis does not prmit of the engagement of 

the head after several hours of strong contrac- 
tions. In the same conditions with a diametei 

Functional Tests of the Gastric Function.— 
Tottman, Munchener medizinische Wochen- 
schrift, has made very complete investigations 
of the gastric function in 60 cases of various more "">" seven and a half centimeters, the 
sorts. In addition to the usual analysis of the choice between the cesarean section and sym- 
tesi meal. Melt's pepsin method was used, physecotomy should bemade for the first when- 
Sahli "s descoid pills were given, and Schmidt's eV(i] . &e , jfe rf ^ mother ^ fo ^ |)e efgr 

test diet was administered in order to deter- , , »,,,., 

,, , -,-. ,. ,, , , ,. red to that of the child. Under the same con- 
mine the ability ot the stomach to digest con- 
nective tissue. As the result of these com- ,lili " ns lhe ehoiee sll01lld be made between 
parative investigations Tottman states that subcutaneous pubiotomy and the cesarean see- 
the use of the stomach tube is the most un- tion according as the life of the infant of the 
P leasanl &* the patient, but in cases of pro- mot her is most important, since section is 

nouneed disease affords very reliable informa- . , a • , « ,, ,.,, , , . ± 

most beneficial for the child, and pubiotomv 
tion. In instances oi milder disorder it is 

less to be depended on and max eve,, lead for the mother - In case of fever or infect ion 
astray, since its introduction may of itself in- P UD iotomy is to be preferred. In contractions 
terfere with gastric efficiency. Schmidt 's diet of more than seven and a half centimeters see- 
a most useful method and is little if at tion is to be preferred to version in the inter- 
ests of both mother and child. Between pre- 
mature labor and hysterectomy we should 
choose the firsi on behalf of the child. In se- 
vere eclampsia forced labor is to be preferred 
in the interests. of the child and mother.— An- 
Patient. Careful preparation of the pills from miles de (i; necologie el d 'Gbstetrique. 

liable to 

error. It is not adapted 

lor re-- 

lied appli. 

•ation, since the patients 


' not Willi] 

lg to resort to it a secon 

d time, 

1 it is also 

unsuitable \\ hen only flu 

id food 

i be taken, 

Sahli's method can be 

used ill 

cases am 

1 is the mosl agreeable 

for the 


Acute Generalizing Peritonitis.— Carwar- abortion, and although it may be induced, 
dine, British Medical Journal, uses the terra atony of the uterus is its most frequent cause, 
"generalizing peritonitis" to cover all those Under such circumstances it may appear as 
cases of rapidly spreading peritoneal infec- early as t he sixth week of pregnancy, aboul 
tion, usually from a primary focus. The com- the time when the serotinal vessels begin to 
nion sites of origin of such spreading peri- undergo rapid enlargement in response to the 
tonitis are the vermiform appendix, the uter- stimulation of the placental chorion. Hemorrh- 
ine appendages, and the gastroduodenal region age may also be due to deficiency of calcium 
by reason of infection or perforation. Within and potassium in the muscular substance of the 
the peritoneal cavity there are certain poten- uterus, or to the presence of some toxic ma- 
tial spaces which may become converted into terial impairing the tone and responsive power 
pools by accumulation of fluid therein. Which of the organ. In such cases potassium iodide 
of these spaces is primarily involved depends and calcium chloride are given to remove 
upon the site of origin, the effect of gravity, deleterious substances or to supply those 
and the guiding direction of the viscera and which are deficient. When the muscular 
omentum, both static and peristaltic. The energy of the uterus is impaired there is 
accumulation of the infective fluid occu- often enfeeblement of the nerve energy also. 
pies the true pelvis; the omentum becomes and strychnine, arsenic, digitalis, or phos- 
fixed to the diseased focus, and tends to local- phorus may be given with benefit. Pain is 
ize the fluid by forming an omental roof, the other all important prodromal symptom 
The writer commends the practice of draining of abortion. It may be noted when the uterus 
serous collections as well as the purulent does not adequately respond to and fails to 
ones, and if there be any apprehension of expand correlatively with the developing 
subsequent infection of any proximate favor- ovum. The uterine tissues, again, may be 
tte site, to anticipate this by putting a drain- responsive enough, but they may be restrained 
age tube into that area, the favorite pools by adhesions. Abortion not infrequently 
being pelvic, right and left lumbar, and right results from physical or mental shock, or a 
and left subphernic. Two recent improve- combination of both influences. After the 
men Is in the treatment of these cases deserve tenth or twelfth week of pregnancy the uter- 
notice. The Fowler position consists in plac- us ma y be injured directly by a blow on the 
lug the patient in the upright sitting posi- lower abdomen, and abortion may more or less 
tion as soon as possible at the time of or quickly ensue. But usually there is extrava- 
immediafely after operation, so that the sation of blood from rupture of the function- 
peritoneal exudation may gravitate to the ally active maternal vessels; the blood may 
lower abdomen, where drainage is provided never make its escape externally, and pain 
for, far away from the more dangerous may be the only symptom. No drugs should 
epigastric areas. Murphy's treatment con- be given in such cases; absolute rest is the 
sists of (1) rapid removal of the focus of in- best treatment. Necrosis of the amniochorion 
feet ion, with little disturbance of the periton- is a very rare cause of abortion, and it de- 
aeum, and closure of the hole in the gut; termines this event by allowing the amniotic 
(2) drainage (a) suprapubic, (b) through the fluid to escape. 
operation incision; (3) rapid operation, pre- 
ferably through the rectum, and no sutures Some Considerations in the Use of Cardiac 
are put in; (4) no food is given by the Tonics — Haines, Folia Therapeutica, points 
mouth for two or three days; and (5) continu- out that of the group of cardiac tonics all 
ous saline infusions by the rectum. The ob- exert some action on peripheral blood-vessels; 
jeet of these last is not to cause the bowels they may cause a most intense constriction, 
to act, but merely to keep a supply of a few as in the case of apocynum or squill, or a very 
inches of saline fluid always in the rectum. small effect, as in that of strophanthus. This 

difference in their action is of some impor- 

Abortion. — Oliver, British Medical Journal, tance when one is treating cases of heart 
defines abortion as the act whereby an imma- disease associated with arterial degeneration 
hire and nonviable product of conception is and high blood-pressure. In these cases 
dislodged from the maternal body. External when dilation of the heart, back-pressure, and 

hae rrhage is not only the most important, all the secondary effects resulting from it 

but the most common premonitory symptom of aie the result of persistently high arterial 


1,1 | pressure, if is obvious that we should The combined action of a cardiac tonic 

no l be contenl in administering digitalis in with a vasodilator of the nature of diuretin 
routine manner. We musl aim not only is to slow ami strengthen the beart-beat and 
al increasing the efficiency of the heart, but to increase the How of blood through the ves- 
at keeping the vessels a- much dilated as pos- sels, including the coronaries. To some ex- 
s jl,l ( . in the circumstances. For this purpose tent the action of the tonic on the vagal end- 
it has jested thai vasodilator drugs ings would be neutralized by the action of the 
particularly the nitrates, should be adminis- diuretin on the excilomolor area, but the 
tered along with the cardiac tonic. Unfor- vagal effect always overshadows the tendency 
innately such a combination does not produce to acceleration, and the heart consequently 
the desired effect. First the nitrate effect beats more slowly. 

overshadows that of the cardiac drug, and Theobromine differs from some other vaso- 
vasodilatation is the prominent feature; then dilators in that it exerts a stimulant action 
the cardiac drug obtains sway, and the dilata on the heart. This was shown in still another 
tion disappear. Nevertheless beneficial ef- instance in which was recorded the heart 
fects have followed the use of erythrol tetra- beats of an isolated rabbit's heart perfused 
nitrate combined with digitalis or strophan- with saline solution. In this experiment the 
thus. addition of diuretin to the perfusing fluid not 
The author points on!, however, that other only increases the rate of flow — that is. 
vasodilators are now known which are almost diiates the coronary vessels— but increases the 
as efficient as the nitrites, but without some of force of the heart-beat. Perhaps one of the 
their objectionable properties; he refers to great disadvantages of administering digitalis 
the purin derivatives — caffeine, theobromine, in cardiac disease is that it tends to diminish 
and theophylline. All these bodies increase the How through the coronary vessels by con- 
the rate of the heart-beat by direct action on striding them. The author believes that this 
the heart muscle, dilate the peripheral blood- effect may be to a great extent overcome by 
vessels as has been shown by Dixon, and giving the digitalis along with a theobromine 
augment the Bow of urine. Caffeine is of preparation such as diuretin. 
course a cerebral stimulant; it at first excites In addition to the coronary vessels theo- 
the vasomotor center and causes constriction bromine dilates all other peripheral vessel-. 
of the peripheral arterioles, the central effect bul owing to the augmented action of the 
for the time being overshadowing the peri- Heart the blood-pressure does not fall below 
pheral dilatation. Theobromine has little 01 normal, but tends to remain even a little 
none of this central action, and so it produces above it. Diuresis is an early effect, and is 
an immediate dilatation of the vessels, and is. secondary to the increased flow of blood 
therefore, a suitable substance for combina- through the kidney — that is, the vascular 
lion with the cardiac tonics in such conditions changes are primary to diuresis, not second- 
as that to which he has referred. It may be ary; there is no evidence to show that diuretin 
administered conveniently in the form of has any specific action on the renal epithelium. 
diuretin. which is a combination of theobro- Such a combination of drugs as suggested 
mine with sodium salicylate, and has the ad- has produced an excellent effect in cardiac 
vantage of being easily soluble. It effects dropsies, failing hearts, and, above all, in 
the heart like caffeine — that is, it increases general degeneration of the cardiovascular 
the tate and to some extent the force of the system, following on persistent rise in blood- 
heat. An isolated rabbit's heart in one of pressure. Fifteen grains of the theobromate 
the author's experiments showed the effect of inf >y be combined with ten minims of a relia- 
dinrelin. suitably diluted with Ringer-Locke hie tincture of digitalis, and administered 
solution, when perfused through the coronary every four hours for two or three days; but 
vessels. One effect noticeable in this experi- ' ( ' s better after that period to omit the drug 
ment, bul which is not recorded on the tracing, f«"' some days, not only because digitalis is 
is the marked dilatation of the coronary ves- cumulative, but because the effect of the drug 
-els. This action on the vessels was noted tends to diminish with repeated use in small 
in another instance by a record of the rate doses. 
of flow through the vessels of a frog perfused 

with a weak solution of diuretin in saline Typhoid Insufficiecy and Noctural Enuresis 

solution. in Children and Adults— Hertoghe (Bull, de 


l'Acacl. R. de Med. de Begle) believes the years. These children were supposed to be 
thyroid gland principle, in the sense of it? perfectly healthy, and for the most part were 
cellular product, is of such importance foi well nourished, and all were subjectively well 
practically all the organs and functions of the Fourteen, of 33.3 per cent., however, had 
organism that an excess as well as a deficiency albumin in their urine without any other evi- 
will lead to disturbances of a serious charac- deuce of nephritis, and on the basis of this 
ter. The thyroid gland presides over the experience Ullmann suggests that this condi- 
growth of the body and regulates the assimi- Hon must be considered as a more or less 
lation and decomposition of food-stuffs. An physiological manifestation of early life. In 
uninterrupted influence is exerted by it upon most instances the tendency is outgrown, but 
the muscles, the nerves, the brain, the skin, when it is found in adults it must be regard- 
the epithelium of mucous membranes and of ed as the persistence of this early condition. 
glands. Also the sexual organs are subor- He therefore does not agree with Leube in 
dinate to it, in regard to their normal or path- regarding the albuminuria of puberty oC this 
ological evolution and function. Hemorrh- author as a disease of development with a well 
ages, abortions, malformations, the imperfect characterized clinical picture, and also does 
or normal development of the fetus; the en- not consider that it should be called orthotic 
tire period of lacatation, and with it the thriv- albuminuria, but rather that the condition 
in»' of mother ami child, are controlled by the should receive the name of juvenile physiolo- 
thyroid gland principle. An excess during gical albuminuria, and be differentiated as 
pregancy may harm the mother to the advan- such. This diagnosis naturally can be made 
tage of the fetus. The growth of the child, only after long-continued and careful observa- 
puberty, adolescence, sexual maturity, etc., are Hon. Treatment is superfluous, for in most 
all under the same influence. Nocturnal en cases the tendency disappears as the indivi- 
uresis is usually due to a deficiency in the dual grows up, and in the others it persists 
thyroid principle. In view of these various in spite of all therapeutic efforts. It is with- 
considerations, the importance of the thyroid out effect on the patient's health or length 
principle as a therapeutic agent is constantly of life, and its presence need not be appre- 
on the increase. fended by insurance examiners. 

Delusions of Grandeur in General Paralysis Ptomaine Poisoning from Mutton with 
of Children — Barbonneix (Rev. Mens, des Mai. Marked Bradycardia. — Bryson, Britsh Medi- 
de l'Enfance) says paralytic dementia is of col Journal, reports the case of a farmer of 
very infrequent occurrence in childhood and thirty-nine years, whose symptoms began some 
adolescence, and at this time of life chiefly three hours ofter he had eaten the mutton, 
attacks idiots and imbeciles. The course is the weather being warm and sultry but the 
a far slower one than in adults, but remissions meat being all right so far as its appearance 
are uncommon. The onset of the disease in- was concerned. Several other who had par- 
terferes with the physical and sexual develop- taken of the same meat were attacked, though 
ment of the patient. AVhile delusions of less violently. The symptoms were the usual 
grandeur are not common in children, they are ones of gastroenteric irritation, vomiting, 
not as rare as usually stated, occurring in diarrhea, tympanites, and some abdominal ten- 
12-14 per cent, of the cases of juvenile para- derness. Later cramps in the extremities were 
lytic dementa. They are characterized, as added. The pulse ran down to 48 and was 
a rule, by the silliness ami childishness of the regular. The breath had a peculiar fetid odor, 
concepts: the patient will say, for instance The symptoms lasted in all over five days and 
that he is enormously rich, for he owns 25 recovery ensued. 
cents, or 500 monkeys. Outside of general 

paralysis, delusions of grandeur in individuals A Possible Explanation of Late Return 
under twenty years of age occur only in de- Case? of Scarlet Fever. — Habgood (Brit. Med. 
mentis precox. Jour.) notes that every physician responsible 

for the discharge of scarlet fever patients from 

Juvenile Physiological Albuminuria. — Ull- isolation hospitals is beset with the difficulty 
niann (Berlin. Klin. Woch.) examined the of knowing when they are free from infection. 
ftrine of 42 small children and school girls be The time having not yet arrived when he can, 
tweeu the ages of two and a half and thirteen as in the case of diphtheria, call in the aid of 


the bacteriologist, he lias to be guided by or- of the disease and says that the patients may 
, Unary clinical examination. Formerly dis- be divided into three groups. The first cata- 
quamation was the guide; when that was com- gory comprises patients who have had the 
pleted the case was discharged. Of recent disease for only a few years and who accord- 
years it has been recognized thai where return ingly have only moderate uratic deposits. 
eases of scarlet fever occur the discharged pa- With these the hydrochloric acid treatment is 
tient will be found to have some purulent or usually very effective and a permanent cure 
mucopurulent discharge. While admitting the is possible. The second class includes cases 
impossibility of being sure thai all inllamma- of chronic typical or irregular gout in which 
lion has ceased in the upper resiratory trac<y in the course of years very considerable de- 
the author is inclined to believe, from obser- posits and tophi have formed. These patients 
vation at different hospitals in the last two also experience great improvement in the gen- 
years, that cases are sent out free from any eral condition and cessation in the progress 
oasal discharge and not infectious, but do of the disease. Further attacks are not alto- 
again bee,, me infectious by the occurrence of gether prevented, but are usually not severe. 
an ordinary attack of nasal catarrh, which The acid is effective only in preventing new 
causes some remaining quiescent scarlet fever deposits and does not cause solution of those 
germs to renew their activity. An analogy already present. In the third group he places 
may be found in the case of one who sits in the severest cases of chronic gout, and patients 
a warm room with a current of cold air play- of this type apparently benefit bill little by 
ing on his neck. lie may get an attack of the use f the acid. The author also recom- 
acute nasal catarrh, and he may become infec- mends the addition of from 2 to 400 grams 
tious to others. The germs that caused the of crude hydrochloric acid to a bath tub full 
catarrh were already in his nose, but dormant of warm water as an efficient means of pro- 
ami able to become active only when an inter- motino; cutaneous activity in gouty patients. with the nasal circulation was set up The patients should stay in the bath about 
by the .-old air driving on to the warm skin, ten minutes and repeat it at intervals of one 
Habgood thinks it may be argued that the or two weeks. 
scarlel fever convalescent causing a "return 

case" has in some instances left the house. Thyroid Disturbances Caused by Iodine In- 

nol in an infectious state, but owing to the toxication. — Warschauer. Berliner klinische 

change from a healthy, open-air life and free- Wochenschrift, reports an unusual instance 

ly ventilated wards of a hospital to the stuffy of intoxication apparently induced by polas- 

and ill ventilated rooms of a cottage he has saium iodide. The patient was a woman "2^ 

become more than usually liable to nasal years of age who came under another physi- 

catarrh — has, indeed, suffered from such an cian's care on account of a chronic eczema of 

attach and is thereby again made capable of one leg. This was considered as being syphi- 

conveying scarlet fever infection. litic in nature and inunctions of blue ointment 

and potassium iodide were administered off 

The Hydrochloric Acid Treatment of Gout: — and on during four weeks. The patient then 

Falkenstein, Berliner klinische Wochen began to suffer from great weakness and as 

schrift, reports on the results of five years' erythema appeared over the entire body, tho 

application of his hydrochloric acid therapy face became edematous, there was loss of ap- 

in gout. This is founded on his belief that in petite, violent diarrhea, subnormal tempera- 

vnut there is a hereditary abnormality of the ture, and a pulse of 100-120. At this time sbe 

Efastric mucosa involving the fundus glands came under the author's observation and the 

and eausiii<_' diminished hydrochloric acid se- potassium iodide was stopped and the diarrhea 

cretion. The method consists in the continu- checked with opium. The condition continued 

ous administration of considearble quantities to grow worse, however; the skin became very 

nf concentrated pure hydrochloric acid, which dry and scaly, the hair fell out, the emancia- 

■•i ■ ei, well diluted after meals. The author tion became extreme, the loss of weight amouaJta 

himself has taken during more than five years ni .- *o sixty pounds in seven weeks, and a 

without any interruption 50 I" 60 drops of consultant made the diagnosis of Addison's 

Ihe concentrated acid withoul any untoward disease. The pulse could no! be counted, nt 

effects, and with very great reliof to his I hues there was delirium, bed sores appeared, 

.-■.nix symptoms. He has treated 390 cases !lll<1 lll( ' " uu ' became albuminous. Earlier in 








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The admirable therapeutic effects of 
guaiacol without its disastrous gastric 
results. Useful in coughs, pneumo- 
nia, typhoid fever, incipient tubercu- 
losis. Procurable in three forms : 
Powder; 5-grn. Tablets; and Syr. 
Thiocol Roche, 6-oz. bottles. 

For Samples and Literature : Mark 
Name of Medicament of which you 
want a Sample; cut out this ad 
and mail it to us with yc 


In erysipelas and chilblains Thigen- 
1 (soluble sulphur compound, odor- 
less on use) is worthy of trial. Airol, 
odorless wound antiseptic has proved 
interesting to many physicians. 

The Hoffmann-La Roche Chemical Works, 90 John St., NeWYorX; 


c reporl of the 

,} for December also showed that tl 

the illness the administration of thyroid tab- The re P orl " r tl,e NeTV York Citv Healtl 

ad been tried, but had been given up 

owing to cardiac distress. Now, as a las. re were L > 202 ,i, ' i,,lis from Pneumonia, many of 

sort, this remedy was again resorted to, later lll( '"' beginning with an influenza. In addition 

on supplemented by sodium phosphate. At <" tuis > there were 12( ' deaths trom inJIufflBa 

dghl days the improvement was wlthout pneumonia. 

verj preceptible and al the end of about foui "• therefore, seems a fitting time to say 

tnontLs the patient's condition was practically something about the preventive treatment of 

.. in all respects. The author regards these Perilous diseases and the value of th< 

ase as an instance of thyroid disturbance following— among other rules recently sug 

o intoxication by potassium iodide. gested '" lhe community at large by Samuel G. 

Tracy, M. 1).. New York, in a communication 
The Minimum Albumin Requisite.— Forster, tn tlu> New V, "' k Times— will bo generally 
Mnnchener tnedizinische "Wochenschrift, in conceded: 

ssing the subjeel of nutrition, says that it Kee P Mouth > Teeth ' Tonsils and Nose Clean 
is coming to be realized that there is a dan- "" is necessary," continued Dr. Tracy, "to 
ger in reducing the albumin intake to the mini- kee P iIh ' mouth, nose, tonsils, etc., clean, be 
mum at which nitrogen balance can be main- eause the mucous membrane of these parts, 
ition to albumin, fat, and car- especially the tonsils, is not infrequently the 
bohydrates the human body requires for the P orl of entry of the ^ erms of several infec 
growth and maintenance of its organs a suffi- tious diseases, as influenza, pneumonia, and 
ciency of other substances such as the inor- aeute rheumatism. The little depressions in 
ganic salts. In food stuffs these are found the lousils are a favorite place for these 
in combination with albuminous bodies or in germs to lodge; when the tonsils are inflamed 
close relation with these, so that if the amount and the vi<al resistance of the body lowered 
of piot,. id ingested is greatly reduced there fl ' om :m - v cause, ,hese germs are taken into 
is also risk of impairing nutrition through de- tlie system, circulated in the blood, and multi- 
ficiency in salts. Furthermore, the breaking P lv witu 8 Teat rapidity. To prevent their de- 
up of albumin in the body results in the for- velopment, it is necessary to antiseptically 
on of certain essential substances such as elease their breeding places and keep them 
the digestive ferments, protective bodies in- dean, especially if one spends a considerable 
ternal secretions, etc. It has been proved for tmie in tlie rooms of those who have influenza 
some of these, and it is probably for the oth- or pneumonia." 

ers, thai their production is in proportion to As a wasl1 for tne mouth and teeth, or 
plitting of albumin in the body, and it is gargle for the tonsils, a tablespoonful of 
therefore to be expected that with low albu- Pon< l' s Extract of Hamamelis Virginica in a 
miii metabolism disturbances in health may re- half-glass of warm water will be found very 
suit from deficiency in such bodies. Until the agreeable and effectively antiseptic — not so 
conditions underlying both of these processes much Sn - perhaps, because of its immediate 
have been more fully elucidated it is desirable destruction of bacteria, as by reason of its 
from the standpoint of general physiology and astringent and sedative action on inflamed 
hygiene to maintain an active proteid metabol- areas > lillls making sensitive and susceptible 
ism and not to reduce the albuminous food t ' ssl|, ' s Less favorable locations for the growth 
stuffs too low. and propagation of germ life, all of which 

also applies to the following combination as 


a spray for nose or throat 

ft Sodii Bicarb. 

Simple Suggestions for the Prevention of Grip Acidi Borici aadrachms ii 

and Pneumonia. Pond's Extract ounces iss 

r l]Mll _ i . Aq. distil q. s. ad. fl. ounces iv 

influenza and pneumonia are now extre !y 

Prevalent throughout the land. It was re- The wash and spray should be used daily 
timated in New York City there were after breakfast and before retiring at night- 
over 20,000 cases: in Baltimore, 40,000; in of tener if much exposed-and to avoid the toxfc 
. 50,000, and the .leath rate was cor dangers of substitutes adulterated with wood 
respondingly large. ak ,,l 1( ,l ;u; | formaldehyde, only Pond's Ex- 





Discharges from the Vagina and Uterine Cavity 

•ts an abort! 
; of Katha 

Mucous Plaques; Prophylaxis and 

By Edward H. Skinner, M. D. 
St. Louis. Mo. 

The proper care of the mouth is a matter of 
importance in the control of the secondary 
symptoms of oral syphilis, especially in view of 
the fact that the average luetic patient has all 
too little regard for any hygienic measure. In 
anticipation of the early onset of the secondary 
oral patches it should be the duty of the physi- 
cian to instruct his patients as to the proper 
prophylactic measures to be adopted that the 
severity of these symptoms may be ameliorated. 

The first thorough examination of the new 
luetic case should include the careful inspection 
of the mouth and teeth. I f we feel incompetent 
to judge of the condition of the teeth we should 
refer the patient to the dentist. The roughened 
edge of a tooth, or an unfilled cavity, may serve 
as an irritant in establishing a mucous patch. 
The dentist will instruct the patient as to the 
proper care of the teeth. The cleaning of the 
teeth after meals, to avoid the accumulation of 
debris, should be impressively taught. We 
should also realize that salivation may best be 
avoided by the attention to the teeth and gums. 

Anticipating the secondary symptons we usu- 
ally attempt to promote the general health of 
the individual by tonics and bodily hygiene. 
We should also try to increase the cellular re- 
sistance of the buccal membrane by local meas- 
ures. It may be well to consider means to this 
end at this time. Bartholow considers a num- 
ber of drugs to be used locally. Hydrastis can- 
adens is recommended as a stimulant to mucous 
membranes. It also has a valuable astringent 
quality and promotes the salivary secretions. 
Hamamelis virginica is also valuable in advan- 
cing the prophylactic powers of the mucous 
membranes. Thymol and menthol have valua- 
bleproperties, influencing fermentation and pu- 

trefaction, and also serving as antiseptic 
They allay the sensibility of the mucous mem- 
branes and arrest the retraction of the gums. 
Boric acid has decided antiseptic and deodorant 
properties. This acid was an important factor 
in tne original Lister antiseptic method. Being 
very mild, it may be used in varying strengths 
without danger. Glycerine has a beneficail 
effect on all mucous membranes, inasmuch as it 
dehydrates and soothes any tissues it may touch 
Combination of the above remedies may be 
made that will serve rot only as valuable pro- 
phylactics, but also as curative agents in any in. 
flammation of the mucous membrane. But we 
should remember that the application will avail 
little if the patient does not assist their action 
by the careful cleansing of the mouth and teeth 
at frequent intervals, not being afraid to use 
the greatest remedy of ala — pure water. 

When once the mucous patch has asserted it 
self we should try to avoid the ula< erting and 
sloughing process that accompanies the oral 
syphilide. It is at this time that our pro phy 
lactic measures show their true worth. The 
mucous patch rarely spreads in the clean mouth. 
Foul secretions and decomposing food stuff favor 
the ulceration of the patces, The best local 
application for a patch is the silver nitratj 
pencil. One application a day will usually suf- 
fice. An antiseptic mouth-wash should boused 
by the patient about every three hours during 
the day. Among the varous combinations on 
the market today one will fiind that Katharmon 
offer advantages. The iniernal administration 
of mercury should be pushed. If we find that 
tne patches persists in spile of the above treat- 
ment we should try a short regime of the 
iodides. Very frepuently the stubbornness of 
oral features of syphilis may be due to the 
mercury treatment. It is in these cases that 
the withdrawl of the metal and the substitution 
of the iodide, with the use of remedies to 
cure the ptyalittc symptoms, will afford relief. 
-The Medical Mirrow, 



tract (the standard among distillates of Eam- 
amelis for over half-a-century) should be pro- 

Post Hemorrhagic Anemia. 

The anemia which follows the hemorrhages 
of trauma, gastric or intestinal ulcers, severe 
epistaxis, child birth, profuse menstruation or 
hemorrhoids presents a clinical picture that 
is so well known that it requires no descrip 

Examination of the blood immediately aftei 
a severe hemorrhage usually shows no ap- 
parent change in its number of corpuscles, for 
the portion lost withdrew the blood as a whole, 
and the portion remaining in the body, while 
decreased in volume, will be found to contain 
a normal ratio of the fluid and cells. Shortly 
after a hemorrhage, however, the tissues of 
the body give up large quantities of fluid to 
restore the necessary volume of the blood and 
a condition of true hydremia ensues. Exami- 
nation of the blood three or four hours after 
a severe hemorrhage, therefore shows a very 
marked oligocythemia. Reconstruction must 
now take pace and the response to the bodily 
demand is sometimes remarkably prompt, but 
in most instances it is a hard up-hill fight 
This is to be expected, for the disproportion 
between the cells and the fluid elements of 
the blood, and the essential depression of all 
vital functions, makes recuperation a difficult 
process at best. 

Much can be done, however, to assist tht 
body in its efforts to restore normal condi- 
tions. The first and most essential require 
ment is absolute rest in a prone position. In 
some instances, it may be necessary for a few 
days to have the couch or bed tilted so that 
the patient's head shall be lower than th< 
feet. Sudden movements or a sudden rising 
to an upright posture must be strictly inter- 
dicted as these are always liable to produce a 
fatal syncope. Following severe hemorrhage, 
the blood pressure is always lowered, and even 
if a certain degree of tension is apparently re- 
stored, it is very unstable, and may be lost in- 
stantly with all of the resulting dangers on 
the heart and central nervous system. 

Another precaution to be taken is to fre- 
quently change the patient's posture from one 
side to the other. The hydremic state of the 
blood, and the loss of blood tension predisposes 
to gravitation oedema in the lungs -and other 
organs, and the simple procedure of changing 
the patient's position often avoids annoying 




Original Communications. 

Achylia Gastrica, bv H. B. 
Kincaid,M. D., Memphis, 
Tenn., 59 

Nephritis, by H. E. Mitch- 
ell, M. D., Birmingham, 
Ala , 62 

Excesses of Modern Times 
and Their Relation to Re- 
lease, by Marion McH. 
Hull, M. D., Atlanta, Ga., 63 

Adenoids: What? Where? 
When ? and How ? by Al- 
bert J. Caldwell, Amar- 
illo, Texas 66 

Abscesses of the Liver, by 
W. A. Bryan, A. M., M. 
D., Nashville, Tenn.,... 67 

Spasmodic Croup in Child- 
ren, by W. T. Grove, M. 
D., Eureka, Kansas 70 

Cases of Head Iujury with 
Operation, by H. Stuart 
MacLean, M. IX, Rich- 
mond, Va., 73 

Contribution to Local Anes- 
theshia, by L. S. Oppen- 
heimer,M.D., Tampa, Pla. 76 

Cinical Gonorrhoea, by 
Thomas W. Murrell, M. 
D., Richmond, Va., 77 

The Menopause, by Albert 
D. Parrott, M. D., Kin- 
ston, N. C 80 

Some Suggestions on Three 
Essential Points in the 
Treatment of Typhoid 
Fever, by Herman Haw- 
kins, M. D., Jackson, 
Tenn., 81 

Truneck s Serum in a Case 
of Arterio-Sclerosis, by 
C. T. St. Clair, M. D., 
Tazewell, Va., 83 


The Tri-State Medical As- 
sociation of the Carolinas 
and Virginia 85 

The Campaign Against Tu- 
berculosis 85 

Influenza 86 

Health Officer for South 
Carolina 86 

A New Medical Firm for 
Charlotte 86 

Southern Medical College 
Association 87 

The Bacteriology of the 
Blood in Typhoid Fever. 87 

D r. Lawrence Edward 
Holmes 88 

Review of Southern Medical 
literature, 88-92 

Book Notices. 

Proceedings of the Ameri- 
can Medical Editor's As- 
socian, by the Secretary, 93 

Manifesto de la Komnuista 
Partie. The Communist 
Manifesto, by Karl Marx 
and Frederick EDgels 93 

Tuberculosis Congress 93 

Applied Physiology, by A.Rhodes, M. D. 93 

Funeral Directors' Associa- 
tion ? 93 

Cosmetic Surgery, by Chas. 
C. Miller, M. D 93 

The Every-Day Disease of 
Children and Their Ra- 
tional Treatment,by Geo. 
A. Candler, M. D 93 


Tubal Abortion 93 

A Case of Swine Erysipalis 
in Man Cured by the Use 

of Serum 94 

Renal Decapsulation in 
Eclampsia 94 

Tubercle Bacilli Entering 
by Way of the Intact Skin 95 

Acute Pulmonary Edema 95 

Remarks on Appendix Ab- 
scess 9c 

Suppuration in the Region 
of the Pharnyx 95 

Genitourinary Tuberculo- 
sis 96 

Gastric Conditions in Wast- 
ed Infants 97 

The Reaction of Bordetand 
Gengou in Respect to the 
Streptococous in Scarlet 
Fever 97 

Dangers and Treatment of 
Placenta Praevia 97 

Mucocele of the Accessory 
Nasal Sinsuses 97 

Dysentery 98 

The Prognosis in Operation 
for Vulvar Carcinoma.. 98 

A Salt Free Dietary in the 
Treatment of Scarlet and 
Acute Nephritis 99 

The Time of Leaving Bed 
After Normal Labor. .... 99 

Goitre and Cardiac Diseases 99 

Haemolysis Through Ser- 
pent Venom 100 

When and How Should an 
Injection of Antitauic Se- 
rum be Given ? 100 

The Genesis of Albuminura 100 

The Action of Paucrea in 
Carcinoma 100 

The Results Obtained in 
Tuberculosis San atoria. 101 

Potassium Permanganate 
Solution for Fissure of 

the Anus 101 

Extract Mistletoe for Hae- 
morrhage 101 

Hemophilia Transmitted 

Through the Male 101 

Methylene Blue for Crack- 
ed Nipples 102 

Clinical Observations on 
the Origin of Fever 102 

The Differentiation of 
Transudates from Exe- 
dates 102 

Acute Poisoning After Oil 
Enemas 103 

Compresses Left in the Ab- 
domen — Prevention 103 

Breast Treatment- -Af- 
ter Treatment 103 

Plrce n t a Previa —Treat- 
ment in Private Practice 103 

The Technique and Signifi- 
cance ef Wasserman's 

Syphilis Reation 104 

Functional Tests of the 
Gastric Function 104 

Twenty- five Conservative 
Cesarean Operations 
Without M at i e r n al 
Mortality 104 

Abortion 105 

Some Considerations in the 

Use of Cardiac Tonic. 105 

Typhoid Insufficiency 
and Noctural Enuresis in 
Children and Adults. .. . 105 

Delusions of Grandeur in 
General Paralysis of chil- 
dreno 107 

Juvenile Physiological Al- 
buminuria 107 

Ptomaine Poisoning from 
Mutton with Marked 
Bradycardia r . 107 

A Possible Explanation of 
Late Return Caesar of 
Scarlet Fever 107 

The Hydrochloric Acid 
Treatment of Gout 108 

Thyroid Disturbances 
Caused by Iodine Intoxi- 
cation 108 

The Minimum Albumin Re- 
quisite 110 

Alcohol in Relation to Med- 
icine 116 

Plural Effusion 116 

Cancer Recurrence 118 

Action of the Gastric Juice 
Upon Starch 118 

Bacterial Conditions of the 
Faeces of the Infant .... 119 

Treatment of Cancer of the 
Larnyx 119 

Appendicostomy in Chronic 
Dysentary 119 


and serious complications. Hon usually gained in medical colleges. 

. qualities of water arc always To bring all such people together has a 
accessary after hemorrhage, but it should tendency also to dissipate any personal jeal- 
never be given in large amounts ai any one ousy, hostility and bitter competitive spirit. 
time. Two or three tablespoonsful at a timt All animosity between people is tempered, at 
by the mouth every few minutes is much nunc least, by acquaintance. Just so far as the 
beneficial than to allow a patient to drink to American Medical Association aims to bring 
satiation. Excessive thirst is always soon aboul a better acquaintance among the physi- 
eontio : ai) enemas (one pint) of saline cians and surgeons of this country, to scatter 

solution, as warm as can be borne, repeated information, to devise means of assisting so- 
every three or tour hours. These also serve ciety in its natural evolution, just so far their 
admirably to very materially raise arterial ten work is a good one. 

It is no uncommon thing to observe com They could do a great many good things it' 
plete anuria for even twenty-four hours after they chose to do so. They eould make them- 
seven hemorrhages, but the warm saline ene selves very effective in stamping oul syphilid 
mas soon correct this condition. and other venereal diseases. There is no sense 

Feeding is one of the most important detail- whatever in these diseases continuing to be a 
in post-hemorrhagic treatment. Liquid food scourge in the land. They are spread by peo- 
should be used in preference to solids for ob- pie who naturally come under police inspec- 
ious reasons, and may consist of milk, beef lion, and could be easily regulated by effective 
extracts, white of eggs, etc. Small quanti- police organization. As it is, nothing whatevei 
i he given at short intervals, as it is being done except in a few large cities. 
must be remembered thai the digestive func- Even this little was not originated by the 
tion is always more or less depressed and can American Medical Association, nor are they 
inly .10 a portion of its usual work. A good lending any moral support to such reforms. 
reliable hematic is early necessary, one that .Much could be done by such an association 
can materially hasten hematosis without en- of physicians in popularizing information 0:1 
dangering the digestive and assimilative func sex relations, that every boy and girl should 
lions in any way. shape, or fashion. Pepto- know something of. 

Mangan (Guide) is one of the most dependable Much could be done in spreading informa- 
remedies of this class and its hematopoietic tion concerning the proper selection of food 
properties an' well known. Under its use the and the best methods of preparing it. 
cellular elements of the blood are rapidly in- Much could be done in the sanitary regula- 
ereased, and the whole physical condition is tion of the home. Some little is being done 
greatlj improved. The various organs resume along this line, and to the credit of the 
their functions and the distressing and dan- American Medical Association. 

gerous effects of hei rhage are safely and Indeed, there is a great field of usefulness 

properly overcome, f or such an organization, and no doubt in 

time this tremendous organization will use its 

American Medical Association. power in the direction of humanizing and civil- 

I- there, then, uothing good aboul the Ameri- jzing tendencies. 

can Medical Association? Again, an association of this sort can raise 

^ r> - ^re ari anj good things about any the standard of their profession by requiring 

;,li •' people of similar aims. To of the members of the society certain courses 

bring together a large number of people fob of study or original research, conferring upon 
lowing any one avocation, for the purpose of members degrees or diplomas indicative of at- 
mutual instruction and harmonious action is a laiuments and special work. 
.'4001! thing. II j s q U ite important thai various members 

11 applies to doctors, as well as artisans, of the profession should know where the best 
The general practitioner, the general surgeon, aleni and the best technical skill is located, 
the specialist in chronic diseases, the special- in order to avail themselves of counsel and as- 
lsl ''■ some one branch of surgery, all coming sistance in times of need. By associating 
together in convention or society meeting, pre- themselves together in this manner the excel 
senting papers on various topics in which they lence of their work as a whole would be rais- 
ar< interested, is extremely beneficial. Such ed, without doubt. Such a procedure is not 
information is vastly superior tu the informs only commendable, but is without doubt the 



fluty of I In' medical profession, in order to 
bring the greatest possible benefit to society. 

But when the American Medical Associa- 
tion attempts to perfect an organization by 
destroying other members of the profession 
who do not happen to agree with them on 
points of medical ethics, and medical and sur- 
gical treatment, then the organization becomes 
|, m eious and dangerous to the best interests 
of society. When an association of doctors 
attempts to procure legislation making obliga- 
tory upon other members of their profession 
any nut hod of treatment or mode of doing 
business, they I ave over-stepped the legiti- 
mate function oi ! medical society. 

A medical society has undoubtedly the right 
to produce if they can superior physicians and 
surgeons who by actual practice demonstate 
the superiority of their work, and thus outrun 
competitors, or drive their competitors out 
of the profession by fair and open demonslat- 
liou of the incompetence of those members 
of the profession with whom they disagree. 
II' one can cure disease and another man can- 
not, this fact will soon appear in results, and 
DO set of men is quicker to appreciate this 
fact than the average layman who must pay 
the bills, who must bear the bereavements of 

No, I would not for one moment discourage 
the organization of the medical fraternity into 
societies. 1 would be glad to see a great medi- 
cal society which should include all honest. 
practitioners of medicine or surgery, all men 
wIki are trying in any way to prevent or heal 
disease. Such a medical society could make 
itself a great beneficence. There is no need 
whatever to copy the methods of the trusts, 
or in resort to the tactics of the modern finan- 
cial pirate. Such a society has only to go for- 
waid, making its members more worthy, more 
competent, allowing the demonstration of the 
sick room and the hospital to convey theit 
argument to the people. 

A medical society that has come together 
mainly, or even partly, to exterminate compe 
tition, to legislate out of existence other people 
who by other methods are trying to become 
healers, such a medical society is no better 
than an ordinary gang of cut-throats, have no 
higher motives than the meanest trust that 
ever disgraced modem civilization. 

"Live and let live." should be the mottc 
of a medical society. Let deeds, rather than 
words, demonstrate fitness. Let the common 
sense of the people be the prohibitive legisla- 

The Key 

fto the only sane medi' 
cal treatment of all 
those forms of dyspep- 
sia associated with a 
deficient gastric juice 
and an enfeebled gas- 
trointestinal muscula- 
ture is found in such 
remedies as tend, by 
their stimulative action 
on the digestive glands 
and muscles, to re-establish their 
normal physiological activity. 

Colden's Liquid Beef Tonic exerts 
a specific action on the entire diges- 
tive tract. It restores the appetite, 
increases the quantity and quality of 
the gastnc juice, and normalizes the 
motility of the gastro-intestinal mus- 
cles. Write for sample and litera» 
ture. Sold by all druggists. 


Sole Agc.s. 
r*V"j Fulton Street, - - Naw Yoftift 

. The C. N. Cririemon Co. 

tion upon which they rely. Let their useful- 
ness to society decide who are the real healers 
and who are the charlatans. Let the praises 
of those who have been cured or healed in 
any way be the corner stone and bulwark of 
their 01 uanization. 

Organize? Certainly! But thieves can or- 
ganize as well as philanthropists. Organiza- 
tion does not sanctify a bad motive. Nor does 
organization condemn a good motive. It is 
the motive behind any organization that 
makes it bad or good. 

It is not the organization of the American 
Medical Association to which I object, but 
it is the main motive that actuates it, the 
central idea that has given it existence, and 
that puts into its hands the dangerous weap- 
ons which ought to condemn it in the minds 
of all fair-minded people. — Columbus Medical 

Making and Keeping Lime Water Official 
Lime water is a preparation of consider- 
able medical importance. While it is compara- 
tively easy to make, it is not so easy to keep 
at standard strength owing to its tendency tc 
deteriorate. Physicians and pharmacists 
should remember that lime water is a solution 


of calcium hydrate Ca(0H)2 an unstable pre- to eacb case on its own merits, and consider- 
paration which is quieklv altered by the ab- ing such points as the state of the pulse espec- 
sorption of carbon dioxide which is always ir ially, the age, previous health and habits, and 
phere to a greater or Lesser extent, the severity and period of the attack. Young 
The atmospheric C02 is absorbed by the lime patients of good constitution are better with- 
water changing the calcium hydrate to Calcium out it. excepl in presence of heart failure of 
Carbornate (CaC03) which being insoluble is crises of some kind. Use the smallest doses 
thrown down. Thus the lime water constant^ possible, and give strict injunctions as to time 
looses strength unless there is an excess of cal- and mode of administration. Watch its effects 
eium imitate in the bottom of the container carefully, and omit it when the critical condi- 
to replenish. The lime water tablet which is tion has passed. Be especially sparing in 
so convenient for making lime water is very chronic diseases, where in most cases it does 
unreliable because the calcium of which it is not the slightest good, but only leads to waste. 
composed, when fresh, is gradually changed to 

calcium carbonate through exposure to the at- Plural diffusion.— Barr, Lancet, states :hat 
mosphere and lime waters prepared from the the aetiology of each particular case of pleur- 
tablets are rarely full strength, even when isy should be settled as far as possible, it be- 
first made. The pharmacopoeia! process of ing most important both as regards treatment 
making lime water from ordinary unslaked and prognxis. Every case Is due to some 
lime is tedious and laborious. Eli Lilly & Com microorgam :ns or their toxins, even 
pany are now supplying an especially prepared following injury or cold, and these secondary 
calcium oxide powder \'\-vr from impurities to chronic illness, such as nephritis. The vast 
present in ordinary lime and of a physical majovih o' ! nses are t.ionvulous but a num- 
condition favoring immediate hydration and ber are i.i'.umatic or due to pneimiov'.'Cei, 
„ 1|)i( ! solution. streptococcu, staphyoei < :i, or colon, typhoid, 

or influeu" i bacilli. Ma : v of these organism- 
are found in the serous effusion, but not so 
the tuberclo baccillus. If there is any evidence 
of tuberculosis in the lungs or elsewhere, the 


For Mak.ngLimeWaterU.S.P. 

This is a line powder in hermetically sealed question may be considered settled Failing 
vials. Each vial contains a quantity sufficient tllis ' tne H"id should be centrifugeu and the 
to make one gallon of lime water of strictly sediment examined for tubercle bacilli and 
t . S. I', strength, by following directions. By cells - lt lll( ' ,,;IS( ' Ih ' tuberculous the cells will 
using Lilly's Lime no decanting is necessary be mostly lymphocytes; if not, the poi.t.i.i- 
and all official lime water can be prepared in phonuclear cells will predominate. A blood 

s-half hour's time as against 24 hours re- count is of assistance, as in tuberculous plu^r- 

quired using ordinary lime. Lime water so is - v tnere is no leucocytosis, whereas in that 
prepared has been submitted to inspectors who associated with other processes there usually 
have found it meeting federal and state re- is - A hemorrhagic effusion is usually assorial - 
quirements. Ordinarily it is belter not to ed with tuberculous or malignant disease. A 
make a larger quantity of lime water than can specific gravity of 10-8 is usually taken to be 
be use, i iii ;, reasonable length of time, and d llie dividing line between exudates and transu- 
is importanl thai the excess of time be left dates - 1)r . v pleurisy is frequently tuberculous, 
in the bottom of the slock bottle lo supply de ,M,< ""' necessarily so. | u pneumococcal pleu- 
licienev caused by tin formation of calcium ns - v 1 '"''' ( ' is llsll;lll . v a 'arge amount of fibrin, 
carbonate described above whether there be much fluid or not. Cases of 

dry pleurisy require very little treatment ex- 
Alcohol in Relation to Medicine. -Finlay, eep i some counter irritation, a diaphoretic, a 
(Scottish Med. and Surg. Jour.) gives the to! purgative, and perhaps a sedative to relieve 

'""'"- : "' V "'" : l,V -'' inl alc ' ;,s ;l ,lm - i; pain, or some strapping of the chest to limit 

very valuable and dangerous one. and put it the amount of movement. In cases of pleural 
in the same eatagory as morphine, strychnine effusion the writer was formerly much more 
atropine, and the like, [f you look upon it as chary of early tapping than at present; in 
a drug you will probably not go very far wrong, tuberculous cases it, caused vascular turges 
Prescribe it with due sense of responsibility cence of the lung and dissemination of 'the 
and not after a routine method, having regard tubercle bacilli. But since he began replacing 




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short chapters on How to Prepare Top 
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A Southern Medical College Association, Graded. Graduating Summer School 
of Medicine situated on the Cumberland Plateau, at Sewanee, Tennessee, 2 000 
feet above sea level, will open its sixteenth course of lectures on April J, lWo, 
and close the last of the succeeding October. 

Four courses of lectures will be required before graduation, with legal inter- 
vals when a full or partial course has already been taken, no interval will be 

A cool and healthful location, good clinical and hospital facilities splendid 
laboratory and anatomical equipments, with up-to-date opportunities for acquir 
ing medical knowledge at reasonable charges for tuition and board, are some 
of the inducements offered. 

For catalogue and information address. 

J. S. CAIN, M. D., Dean, Sewanee, Tennessee. 

PRACTICAL BRANCHES: John S. Cain, M. D.; James B- Murfree M D.; Deering 

J. Roberts, M. D. ; William C. Bilbro, M. D.; Haydeu A. West, M. D.; Elmer F. 

Hay den, M.D. 
SPECIAL BRANCHES: Hampton L. Fancher, M. D.; Marion R. Moorman M IX; 

John P. Corley, M. D.; Arthur H. Noll; Samuel Stein, Ph. G.; Mason Guill,M.D 
FUNDAMENTAL BRANDHES: Cameron Piggott, M. D.; William B. Hall, A. M.; 

M. 1) ; Joseph M. Selden, M. S., M. I).; Harry C. Reese, M. D. 
With Assistants and Demonstrators in all Departments. 


the withdrawn fluid by air. he now removes the often necessary, due to early mismanagement. 
whole of the effusion, even in tuberculous 

cases, at an early stage with perfect impunity Cancer Recurrence.— Kyall, Lancet, as the 
He now recommends the complete withdrawal result of his observations, has concluded that 
of the effusion in all cases, hut before any carcinoma is highly infectious disease. Not 
great negative pressure is established, and he- that there is any evidence to support the fact 
fore the patient feels any discomfort , he stops of its coinniunicability between one person. 
thesiphon and introduces about an equal quan- and another, but that once an individual be- 
tity of air to the amount of fluid withdrawn, comes the subject of cancer there is not only 
The siphon is then reestablished ami the with- the liability of its spreading by a well defined 
drawal of the effusion completed. When all infective process, but also in those cases where 
the liquid is withdrawn 4 c.c. of adrenalin so the surgeon attempts to remove the disease 
lution (1 in 1,000) diluted with S or ll) c.c. of there is a risk of reinfecting his patient from 
sterile normal saline solution, is injected; this the growth which he is endeavoring to remove, 
contracts the blood vessels and lessens the sec- Cancerous infection of wounds is therefore of 
retion, hut its effect is not very prolonged, comparatively frequent occurrence, but unless 
especialh if any great negative pressure ex the infection manifests itself fairly early the 
ists. If necessary, more sterile air is then in- proof is easily overlooked. Cancer infection 
troduced, so as to make the total amount equal during operation is responsible for many of 
to one half or three fourths of the bulk o*' the cases of recurrent nodules in the site of 
the fluid withdrawn. The larger quantity of operation wounds, and suture hole infection 's 
air is introduced in tuberculous cases. By this exceedingly common. Cancer infection is 
method the patient suffers no discomfort ex- probably the reason why chronic carcinoma- 
cepi from the slight thrust of (he trocar. The tons growths so frequently run a very acute 
siphon is preferred to the aspirator because course after attempted operations. In the pa- 
the force of the suction can be readily regulae- rent growth the cells are more or less encap- 
ed. and. since the tube only reaches to a recep- suled in fibrous tissue, but some cells escape 
tacle on the floor, practically the negative during operation and find a resting place in 
pressure never exceeds one pound to the square the wound which is comparatively unprepared 
inch; this force is greatly exceeded by the to meet and to resist the invasion. The ques- 
aspirator, and the greater the negative pres- tion of cancerous infection of wounds during 
sure the greater the risk of secondary hyper- operation is a. real and exceedingly grave dan- 
tfemia or oedema. ]l is an advantage to intro- ger and one of the utmost importance. More- 
duce a manometer in the air tube; the dange* over, it is danger that cannot be too carefully 
of producing a positive pressure in ihc pleura guarded against, and any failure to avoid it 
• an thus be avoided. Of course, all aseptic has an important bearing on the question of 
precautions must be taken. Empyema is a cancer recurrence. 

disease which has passed entirely into the sur- Action of the Gastric Juice Upon Starch.— 
-* s ' ha^s; they think only of free drain- Roger and Simon, La Presse Medicare, con- 
age and are careless whether the lung ever dude from their studies that throughout the 
expands again or not. The author recommends digestive tract, from the mouth through the 
that a local and not a general anaesthetic be intestine, starch undergoes modifications con- 
used - A fre « incision should be made in a stantly from the action of the various fluids 
very dependent spot, about the eighth or ninth with which it meets. The saliva does not act 
intercostal space, in a line with the lower angle ,,,„,„ it alone in the buccal cavity, but again in 
of the scapula. An assistant should compress the intestine, where its action is reinforced by 
the side so as lo drive oul the pus and allow that of the pancreatic juice. The gastric juice 
as little air as possible to enter. No drain- takes its turn in the production of chemical 
; " J '' tube sl|,lllM '"' introduced, bul a piece of and physical transformations of the starch 
0lled s,lk sl "" lM '"' P ] aced over the wound to it plays an important part in the preparation 
act as a valve and keep (he air out. The pa- Tt continues the action commenced by cooking 
, "' 1 " sll " n1,1 lie "" ll! '' affected side and should and gives rise to soluble starch and' dextrine, 
be well strapped to prevent movement. The if it is incapable of the production of sugar 
vanely of microorganisms in (he pus should of the starch for its ultimate transformation 
be ascertained and an appropriate vaccine 
used. Unfortunately Estlander's operation is Bacterial Condition of the Faeces of the 

Infant. — Nobecourt and Rivet, La Semaine 
Medicale, state that the microbic flora of the 
digestive canal of an infant in a normal con- 
dition is very poor at the level of the stomach 
and duodendum, and gradually grows richer 
as the rectum is approached. In the upper 
segments of the intestine aerobic, or faculta- 
tive anaerobic, germs predominate; in the low- 
er segments, particularly the large intestine, 
the aerobic species become rare and the anae- 
robic predominate. The bacterial flora of the 
faeces is practically that of the large intes- 
tine, which differs markedly from that of the 
other segments. Bui as the composition of 
the faeces is partially determined by the diges- 
tive processes which lake place in the stomach 
and small intestine, the flora is modified when 
these processes are interfered with. Hence 
the bacteriological study of the faeces can re- 
veal not simply the bacterial state of the colon, 
but thai of the upper segments of the intestine 
as well. The authors then consider the varia- 
tions which are found in the flora in diarrhoeal 
conditions, and also the variations which are 
found to result from the ingestion of various 
kinds of food. The therapeutical indications 
to be drawn from these studies are confirma- 
tory of those suggested by clinical observation, 
that, when we have to deal with a very liquid 
and abundant diarrhoea associated with an 
aerobic flora, albuminoid elements should be 
introduced to the food, while, when the diar- 
rhoea is foetid and less abundant, generally 
associated with an anaerobic modification of 
the flora, a starchy diet should be given and an 
albuminoid is confraindicated. 




tyre's Antiseptic Powder. 

The absolute purity of every one of its several 
constituents is definitely determined before it enters 
the blending-room. 

Every detail of the production of 

is supervised by skilful and experienced chemists. 
It is because of these painstaking efforts that the 
preparation affords better results than extempo- 
raneously prepared "Antiseptic Powders" in the 
treatment of gonorrhea, leucorrhea, etc. 

Chemical and bacteriological reports sent 
upon request. 

3. $. Cyree, Chemist, up«m«*«. d. e. 

Treatment of Cancer of the Larynx. — Send- 
ziack, Revue Hebdomadaire tie Laryngologie, 
D'Otologie et de Rhinologie, analy- 
zes 982 cases of surgical interven- 
tion on account of cancer of the larynx 
and concludes that the surgical treatment is at 
present the more rational ; 20 per cent, of the 
962 patients were cured. Deaths have greatly 
decreased since 1SSS, a decrease which he 
ascribes to the performance of th 
at an earlier period and the improvement of 
the operator's technique. When the various 
procedures are compared, none before 1888 
being considered, the method of laryngoflssure 
is found to be credited with 50 per cent, of 
cures, the endolarvngeal method with 46 per 
eent., partial or unilaterial resection with 23 
per cent., and total resection with 22 per cent., 
results which would seem to indicate that 

laryngoflssure was the preferable method.. 
Bu( when recurrences are taken into account 
another story is told; recurrences were 22 per 
cent, after laryngoflssure, 30 per cent, after 
partial or unilateral resection, 33 per cent 
after removal by the endolaryngeal method, 
and only 16 per cent, after total resection. He 
considers total resection to be certainly indi- 
cated when the cancer is very extensive or 
greatly advanced and when the disease has 
recurred after laryngoflssure. 

Appendicostomy in Chronic Dysentary — Pot ■ 
tinger, Lancet, states that the most striking 
result of this operation is the facility with 
which the irrigation of the large bowel can 
be effected. It has also been employed in 
chronic constipation for the administration of 
operation suitable medicinal remedies having a local 
action, while its use has been suggested in 
complicated cases of enteric fever and in cases 
requiring gastrostomy as a substitute for the 
graver operation. It is in dysentery, and mora 
particularly the chronic variety, that the oper- 
ation seems in some cases to give very gratify- 
ing results. The author records the history of 
a man of twenty-seven years who had been 
ill for six weeks, having as many as twenty 


daily passages of mucus and blood. The pa- possibility of the beai being influenced by out- 
lii-ui did admirably and a perfect cure result- side nervous impulses; this would give a suf- 
ed. The author calls attention to a few teehni- ficienl explanation of the large nerve supply 
cal points as illustrated by the progress of to the heart. Attributing the rhythmic pov/'Jt 

this particular case. The catheter Mas at firs', of contraction to the muscle, is, of course, only 
removed between each occasion of irrigation, a very partial explanation of Hie cardiac beat, 
but it was found that even in twenty-four the cause of which lies deeper in physieo- 
hours the wound closed so, owing to the growth chemical changes in the cells. 
of granulations, that it was somewhat difficult Tuberculous Chlorosis. — James. British 
instrumeni was used and was left in the open ■ Medical Journal, states that when we meet 
removed each day. of course, to be w Jth a case which presents in a, more or less 
cleaned. Care was taken never to have a big marked degree all the ordinary appearances of 
"head" of fluid and no attempt was ever chlorosis, and which yet on examination or the 
made to dilate the bowel, free passage through blood reveals the number of red corpuscles and 
the rectal tube obviating this, which in an ex- the percentage of hemoglobin to be practically 
tensively ulcerated condition of the gut would normal, we are very likely to find in it a his- 
liave been a. true danger. tory of past or present tuberculous disease. 

This condition, often occurring in young' wom- 
The Automatic Rhythm of the Heart.— (.Jos- e n, is one which long ago Trousseau recog- 
sage, British Medical Journal, comments on n ized and called false chlorosis or tuberculous 
the prolonged controversy during the last anemia; and although in recent times, when 
twenty-five years as to the origin of the auto- blood examination has become more of a rou- 
matic power of the heart to beat rhythmically tine procedure, the coexistence in tuberculous 
and reviews the various stages of the discus- disease of an anemic appearance with a practi- 
sion. He note, thai the arguments adduced ea lly normal blood count is quite recognized, 
srto are on the whole rather in favor of it seems that in cases apparently of chlorosis 
the venous origin of the stimulus, but declares this possible association of tuberculous disease 
that they are not incompatible with a muscu- often passes for long unrecognized. Inasmuch 
lar fiber source. It has been disproved that as the recognition of such cases is important 
every cardiac muscle fiber is capable of supply- from the points of view alike of diagnosis,, 
ing its own stimulus and beating independent- etiology, pathology, and treatment, the his- 
l.v. It is certain, however, thai the muscular lories of three cases of this category are given 
fibers possess the properties of contractility, in detail. In a general way such cases, though 

'■ luctivity, and tonicity, and it is probable tnore tedious than those of ordinary chlorosis. 

that these are experienced during the norma] recover fairly well. But although their gen- 
b'eal of the heart without the intervention of e ral condition may improve, the blood count 
the nervous tissue. It is also certain that a!! remains practically the same. It is believed 
the muscle fibres are not capable of building that such cases present in reality an oligemia. 
up a stimulus for themselves, but there is evi- that is, a diminution in the total amount of the 
deuce to show thai certain fibres of peculiar blood. Trousseau believed that iron should 
structure possess this property. While certain be avoided and placed his reliance on arsenic 
neurogenic theory, especially the response of and general hydrotherapy. The author be- 
Ihe quiescent heart to th< stimulation of tiic Meves that the condition is one which occurs 
facts see,,, to find their explanation in the ; n individuals who, as the result of hereditary 
accelerator n are otheis pointing ao or acquired causes, have given indication? that 

strongly to Ihe hypothesis thai Ihe hean beat they possess low resistance power to the tnber- 
'- P urel y muscular; and in 'he face of Engle- cle bacillus. In what and to what extent thid 
mann's direel observations on the great veins blood effects may be salutary as regards tuber- 
in frogs and the occurrence of pn Nation in the tubus lung disease, we can only conjecture, 
embryo hear) before developmeni of nervous The author's idea is thai it maybe by indtic- 
elements n seems to me thai the complete ing an air hunger, .and so stimulating lung 
myogenic theory has the more weighty evi- function and nutrition. Anyhow, when we re- 
dence in its favor, and should be accepted until fleet that the quality of the blood is quih 
stronger arguments are broughl againsl if. pood, we can understand thai treatmou. to 

Tliec ''I' 11 "" tbal the rhythmic beai is pure- improve ihe health generally rather than tin; 

muscular in its origin does no1 preclude ihe blood specially is what is required, 

The Charlotte Medical Journal. 



No. 3 

Are Our Rights Threatened ? 

By Dr. H. C. Buck, Friars Point, Miss. 

At a recent meeting of our local Medical 
Society a set of resolutions' from the Ken- 
tucky State Medical Association were in- 
troduced and read for consideration and 
adoption, the sum and substance of which 
was that we as a body and as individuals 
pledge ourselves to use only such remedies 
in our practice as are recommended and 
endorsed bv the A. M. A. or the author- 
ized agents of that body, known as the 
Council on Pharmacy. 

The section or article of these resolutions 
that mostly concern those of us who are of 
the rank and file of the profession reads as 
follows. "Resolved, that we request every 
physician in Kentucky to procure a copy 
of the abridged U. S. P. and formulary 
and be guided by this and the approval of 
the Council on Pharmacy in their use of 
medicine." I do not know that the Coun- 
cil on Pharmacy endorse or sanction these 
resolutions, if they do it seems to me the 
most stupenduous piece of bigoted egotism 
it has ever been my misfortune to behold. 
Who is the great Council on Pharmacy, 
that the U. S. P. should need their endorse- 
ment and approval? Are not the men who 
revised and compiled theU.S.P, fully as well 
versed in Materia Medicia and Therapeutics 
and as able to advise as to the remedies to be 
used as are those who composed this body. 
Certainly it would seem so to me. Ever 
since medicine has been known and men 
have practiced medicine there have been 
various sects or schools of medicine radi- 
cally differing in their ideas and teachings 
regarding disease and the proper remedy or 
drug that should be used in the effort to 
cure disease. In this age we have Alo- 
path (or regulars as we call ourselves) the 
Homeopath, the Eclectic and many others, 
each one of which claiming their method 
the only correct one. While this is not true, 
it is true there is much that is good in each 
and much that is worthless in all, while I 
admit the Council on Pharmacy are doing 
a good work, they are the agents of the A. 
M. A. and that body is the official repre- 
sentative of the Alopathic school, hence it 
naturally follows as a matter of course they 
do not take cognizance of remedies advo- 
cated by other schools. 

I believe if there is any man or set of 
men who should adopt as their motto 
"Prove all things, hold fast (only) to that 
which is good" it should be the physician 

and he should go to the bedside of his pati- 
ent untramelled by the dictum of any man 
or set of men but free to use the best means 
at his command to relieve and cure his pati- 
ent regardless of the sect or school that 
recommends the means or remedies he em- 
ploys. That old saying, the powers that 
be are ordained of God" does not hold good 
in every case. I have seen instances where 
I thought his Satanic majesty had more to 
do with it than did the supreme being. I 
have always lived in the south, was born 
before the war hence I was a rebel and 
(perhaps) unfortunately for me I have nev- 
er been fully "reconstructed," therefore 
that rebellious spirit that is in me and will 
not come out and gets on its hind legs 
when I know or feel that any man or body 
of men are infringing on my rights and I 
deny the right of the A. M. A. or any other 
body of men to dictate to me what remedies 
I shall or shall not use, I claim that so long 
as I comply with the laws of the land in 
which I live I am accountable only to my 
God and my patient for my acts toward 
them, it is not my intention to exploit any 
remedy or set of remedies. I leave the 
choice of remedies to each individual phy- 
sician as he alone should be the best judge 
as to what is best for his patient. I only 
plead for freedom, the freedom granted 
every one in this great county, of our, free- 
dom of thought, of judgment, of action 
untramelled by the dictum of any man or 
set of men. Whither are we drifitingl There 
is a fight being made on the independent 
medical journal. In some states an effort 
is being made to get a law enacted forbid- 
ding physicians dispensing their own medi- 
cine and compelling them to send all their 
prescriptions to the druggist. Now the 
Council on Pharmacy or its great admirers 
want us to let them say what remedies we 
shall use. Truly it is a gloomy outlook, if 
those things come to pass. All independent 
thought and investigation is killed. The 
great Council on Pharmacy will think and 
investigate for us, while the equally great 
J. A. M. will dish out to us such articles as 
they in their wisdom think we should read, 
while (to use an expression of one of our 
forefathers) we can "lie supinely on our 
baik" and do as we are told by the bosses, 
But in contrast to this spirit of bigotry and 
there is and has been for seme time a spirit 
of liberality and tolerance, one for the other 
in the different schools of medicine, seem- 
ingly an inclination to draw nearer togeth- 
er and accept the good each or all may offer. 



This, I think, should be fostered and en- 
courged in every honorable way and 1 be- 
lieve I am safe in saying the liberal minded 
leaders in the profession are doing- this and 
do not hesitate to prescribe remedies from 
other schools than their own and do not 
hesitate to endorse them. This is as it should 
be, but with all due respect to the A. M. A. 
it does not seem as if the present leaders of 
that body favor such a course. In adopt- 
ing these resolutions we virtually agree to 
wholly submit to the guidance of the Coun- 
cil on Pharmacy in the remedies we shall 
use. When a physician reaches the age or 
condition wherein he cannot or will not be 
guided by his own knowledge and judg- 
ment as to the remedy or remedies best 
adapted to benefit his patient, he has reach- 
the age when he should feel in duty bound 
to those who trust their lives in his care to 
follow Osier's advice and get on the shelf 
or take chloroform, be his age what it may. 
While counsel and advice are good and 
should always receive proper consideration 
and respect, when it becomes an obligation 
it is no longer advice. There are very few 
well informed physicians that are willing 
to discard a remedy they have tried and 
know to be good, simply because such rem- 
dv is not recommended by the Council on 
Pharmacy. Long years of experience have 
taught many of us that a remedy that gives 
good results in the hands of some may 
prove very unsatisfactory in the hands of 
others, again a remedy that is beneficial in 
treating certain diseased conditions in one 
person may prove very unsatisfactory in 
another whose symptoms are seemingly 
identical, I have often had this experience, 
hence I say, let the medical profession, 
especially those of us who are country doc- 
tors, remain free and untrammelled in the 
treatment ot our patients, but let each of 
us study our cases and study our remedies 
and do what our honest unbiased judgment 
prompts us to do, if we have not a suffici- 
ent knowledge of drugs and their effects on 
the system to know what to use and what 
to let alone we have no right to practice 
medicine; if we know these things, then we 
do not need the dictation of the A. M. A. 
There seems to be a spirit of usurpation 
and dictation abroad in the land, in all 
walks in life a seeming desire to curtail 
man's rights and privileges. To the young 
men in the profession, those who are at the 
beginning of life's journey, while 1 am now 
near it's close, would say: 

"Be not like dumb driven cattle." 

be men, think, judge, act for yourself, cul- 
tivate a habit of independent thought and 
investigation, guided but not controlled by 
the study and investigation of the learned 

men of the profession, jealously preserve 
and protect your independence, be ever 
open and ready to receive knowledge re- 
gardless as to the source of such knowledge; 
many valuable truths have come from very 
humble sources. Take for your motto the 
words of Thomas A. Kempis, who said, 
"mark not who said this or that, but mark 
the words spoken," into your keeping, soon- 
er or later will rest the honor and integrity 
of our noble profession, make yourselves 
worthy of the trust, no man can carry 
your burden. On your shoulders alone it 
must rest and you alone will be held account 
able to God and your fellow man for the 
life you lead. Rest assured you will find it 
the part of wisdom to. think for yourself. 
Study closely the different theories advanc- 
ed and judge them on their merit not on the 
merit or reputation of the man who advan- 
ces them. 

Open Method Treatment of Epitheleoma 
on a Muco-Cutaneous Surface. 

By W. D. Witherbee, M. D., Professor of Electro- 
Therapeutics and Skin Diseases, North Carolina 
Medical College, Charlotte, N. C. 

Kpitheleoma very frequently makes its 
appearance somewhere in the line of junc- 
tion between the skin and mucous mem- 1 
brane. Whether the primar)' specific cause 
is that of chronic irritation or not, has not up 
to the present been satisfactorily answered. 
If a case of this kind is seen early and 
watched from time to time as the disease 
progresses one cannot help but note how 
much more rapidly the portion in the mu- 
cous membrane advances, than that con- 
fined to the skin alone. The same differ- 
ence is also seen when the disease is entirely 
confined to the mucous membrane and com- | 
pared to the same condition in the skin in 
any part of the body provided that in neither J 
case irritant remedies are applied. 

The chief reason, if not the only reason, j 
that malignant cells grow and reproduce 
more quickly in the mucous membrane 
than in the skin is because it is much more 
richly supplied with blood. Recurrence 
after enucleation from a mucous surface 
always appears much earlier than when a 
similar condition is treated in the same way 
in the skin for the same reason. An epi- 
theleoma, therefore, that involves both the 
skin and mucous membrane if radically 
removed, we naturally look for recurrence 
first in the mucous membrane adjacent to 
the wound. .Anything less than a most 
thorough radical operation for the removal 
of an epitheleoma in or invading the mucous 
membrane will just as certainly be followed 
by a recurrence, of a vastly more malignant 
type than the original tumor, as when a 



caustic paste is applied to an epitheleoma 
of the skin which does not destroy all of the 
embryonic cells present. In other words 
the operation itself on a mucous membrane 
causes as much reaction as the caustic does 
to one in the skin. 

With the above facts in mind it might be 
well to try and determine why local irrita- 
tion of any epithelioma, be it chemical, 
mechanical or surgical, causes 9uch a mark- 
ed increase in the malignancy of embryonic 
cells. Irritation of any kind causes in- 
creased circulation and increased circula- 
tion causes increased function. If this be 
true, all of the cells left in or about the 
wound, both normal and pathological, are 
stimulated by the increased circulation and 
therefore the malignant cells, which at the 
time of the operation or irritation, have 
already won supremacy ever the local nor- 
mal cells, redouble their powers of invasion 
and thus produce the most malignant form 
of recurrence. 

We have already referred to the operation 
on a mucous membrane for epitheleoma as 
causing the same amount of reaction as 
when a caustic is applied to one in the skin; 
at the same time assuming in both cases 
that some of the malignant cells were left 
behind. Some surgeons may disapprove 
of such an assertion, but where is the sur- 
geon who has yet devised an apparatus or 
technique by which he can say positively 
that he has removed every cell that is malig- 
nant in character? No matter how radical 
the operation may be. On the other hand 
if this is impossible by what right has any 
one to sew up a wound from which a malig- 
nant growth has been removed and not 
employ drainage? As well as daily X-Ray 
exposures to destroy the few embryonic 
cells remaining which are by this means 
changed from a deep to a more superficial 
position and may not be entirely removed 
by drainage. 

The "Open Method Treatment" then of 
an epitheleoma of the lip which involves 
both skin and mucous membrane and has 
not yet invaded the cervical glands would 
be as follows: The mass is removed by the 
usual radical procedure, with the exception 
that no undue pressure is applied to the 
tumor, in order that none of the cells are 
expressed from the original mass into the 
neighboring tissues and glands. This done, 
an incision, going well down to the base- 
ment membrane, beginning at the edge of 
the lip and continued around the cut sur- 
face of the mucous membrane, is made. 
This incision cuts off the blood supply tem- 
porarily from the mucous tissue around the 
wound and thus prevents the reaction or 
increased blood supply due to the irritation 
of the operation. The wound is left open 

to obtain free drainage, and daily X-Ray 
exposures are then made until the wound 
heals by granulation. By this means the 
malignant cells remaining after the radical 
operation, which caused the recurrence, 
are not only starved by cutting off the circu- 
lation locally but are also, by leaving the 
wound open, changed to a more superficial 
position in order that they may be drained 
from the wound or destroyed by the Ray. 

Malformations of the Mouth and Cleft 

By M. F. Coomes, A M., M D., LL.D., Louisville, 
Ky., Professor of Physiology, Ophthalmology, 
Otology and Laryngology in the Kentucky School 
of Medicine; a Member of the American Medical 
Association, the Kentucky State Medical Society, 
and the Louisville Clinical Society; Ophthalmic 
Surgeon to the Louisville City Hospital, and the 
Kentucky School of Medicine Hospital; Consult- 
ing Ophthalmic Surgeon to Sts. Mary and Eliza- 
beth Hosyital; Ophthalmic Surgeon to St. An- 
thony's Hospital, etc., etc. 

In presenting this subject to you for con- 
sideration I do so for the purpose of making 
a plea for a more thorough consideration of 
the surgery of cleft palate. The general 
surgeon is not overly anxious for such work 
because of the great amount of time requir- 
ed to do it, and a chance of failure. Again 
the amount of money to be obtained for the 
average of these cases is not at all in keep- 
ing with the time and skill required to per- 
form the operation. This, coupled . with 
the unsatisfactory result so often obtained, 
causes many surgeons to let some one else 
do the work, not caring to have the failure 
credited to them. 

It is rather a strange fact that so little 
sympathy is manifested for these unfor- 
tunates by their fellow man. A child with 
Strabismus is pitied, and its condition com- 
mented upon, and the parents are urged to 
have the defect corrected — but not so with 
the little one with the cleft palate, it is left 
to whine and grunt and a suggestion of 
relief is rarely ever made in its behalf. 

Not long since I operated upon a grown 
young man who had Hare Lip. I asked 
him why he waited so long. His reply was 
that "no one had ever told him that it could 
be done until recently." 

There has been but little of this kind of 
clinical work done in the medical colleges, 
and the teacher of general surgery often 
does not mention it in his course of lectures 
— hence the general practitioner of medicine 
may never have heard a lecture on the sub- 
ject of cleft palate, nor have seen a case 
until he chanced to meet with it in practice, 
and under such circumstances he is not 
likely to give any positive course to be pur- 

*Read before the Jefferson County Medical So- 
ciety January 13th, 1908, Louisville, Ky. 



sued by the parents of the unfortunate 

The surgeon that does this work must 
study each case so that he may have in his 
mind's eye, when he commences the opera- 
tion, a clear understanding of the tissues 
willi which he is to deal in order that the 
disposition of each part may be correctly 
made. An improper cut, or a misunder- 
standing as to what is to be done with any 
particular structure, would make it impossi- 
ble to do the work in a proper manner, and 
a failure or imperfect result would follow. 

'flu- operation for restoring the cleft in 
the hard palate is the "Pons Assinorum" 
in surgery: in other words, the "jackass 
bridge." There may be some general laws 
laid down for this work, but no hard and 
fast lines can be followed in doing any one 
of these operations. Each case is a separate 
and individual case of itself requiring 
special study as to the mode of procedure, 
and especially as to the means of gaining 
the desired end. This is true because of the 
multiplicity of complications accompany- 
ing these cases — as to the shape of the sep- 
arate parts — one end may be longer than 
the other; there may be more tissue on one 
side than the other; the curvature of the 
bony margin on one side may be greater 
than that on the other, and so on I might 
run through the variety of deformities that 
are met with. Considering these facts it 
will be seen that the ingenuity and the sur- 
veying powers of the surgeon will be exer- 
cised to their limit in order to meet the 

Malformations of the Month. 

Under this head are usually classified all 
of the clefts found in the lips and face as 
well as those met with in the hard and soft 
palate. It is fortunate for the surgeon and 
the patient that these malformations occur 
most frequently in the lips and soft palate, 
because they are more easily remedied than 
those of the hard palate. 

In this paper I shall not attempt to dis- 
cuss the causes of these malformations other 
than to say that it is the failure on the part 
of nature to do its work, and possibly 
heredity. There is a mistaken idea on the 
part of many physicians and surgeons as to 
the actual condition in the cleft palate, and 
especially where the cleft is complete through 
the hard palate. This mistaken idea con- 
sists in the belief that there is a deficiency 
in the quantity of tissue present. 

We are indebted to Dr. Brophy of Chicago, 
for the most enlightened consideration of 
this subject. He has shown that in these 
cases there is rarely a deficiency in the 
amount of tissues, and the successful man- 
ner in which he has devised and carried 

out his ideas shows beyond all doubt that 
he is correct as to the conditions existing 
in cases of cleft in the hard ypalate, and 
that his mode of operating is the correct 
one is proven by the results obtained. It 
is a displacement of tissues and not an ab- 
sence of tissues. With these facts before 
us the question of correcting the defect is 
the next step. 

The time at which the operation should 
be performed is always a question that de- 
pends upon the nature of the defect to be 
corrected, and the age and general condi- 
tion of the patient. If it is a new born 
child with a cleft through the hard palate 
it should certainly be done before the child 
is six weeks old, probably the most pro- 
pitious time is when the child is three weeks 
old. This operation should be done with- 
out any interference with the lips, leaving 
them and the soft palate for subsequent 
operations. The lips in from three to four 
months after the cleft palate, and the soft 
palate when the child is from fifteen to 
twenty mouths old. After children have 
arrived at the age of six years it would seem 
that any period is the time to operate, that 
is, whenever the surgeon and the patient 
are ready. I believe that children at the 
age of twelve years or thereabouts could be 
operated upon more satisfactorily because 
having arrived at an age where we could 
have better control, their own intelligence 
assisting us greatly in caring for the wound 
after the operation. In adults any time is 
the time when the patient and the surgeon 
are ready, save in females who should not 
be operated upon during the menstrual 
period or thereabouts. In all children a 
general anesthetic should be used and the 
Trendelenberg position maintained. This 
is apparent to every one, because in that 
position the blood is kept away from the 
larynx, and the operation which is bloody 
and slow can proceed so far as interference 
with respiration is concerned. It may be 
well if the operator has the time to give the 
patient (whether child or adult) enough 
belladonna to dry up the secretious of the 
mouth so as to be free from excessive saliva 
which always accompanies these operations. 
If the operation to be performed is for cleft 
in both the hard and soft palate then the 
surgeon should proceed not according to 
any strict rule except that of his own, be- 
cause no hard and fast lines can be marked 
out for these cases. Usually it is best not 
to interfere with the edges of the cleft until 
after the other portion of the operation has 
bean done, namely, that of lifting the soft 
tissues and periostium and sliding them into 
position. When this has been done then 
the edges may be freshened and the sutur- 
ing can be proceeded with. I have occas- 



ionally freshened the margins of the two 
sides before the sliding operation has been 
done, but I do not know that there is any 
special advantage in this — others have pro- 
ceeded in the same manner. 
The Prognosis. 

The prognosis as to results of these oper- 
ations is difficult to arrive at. As to the 
closure of the lip it may be safely said that 
in nearly all cases with the exercise of 
proper care, and a thorough study of the 
case before operation, and I mean by that, 
a thorough study of just what you have to 
deal with, that is, how much tissue you 
will have and where you will place it. If 
this point is thoroughly considered a fairly 
good result can always be expected as to 
function and cosmetics. 

Prognosis of Operation on Soft Palate. 

With our modern advances it is pretty 
safe to say that we may expect to close up 
the soft palate in nearly all of these cases, 
although it will often require repeated 
efforts to do so, and the greatest care on the 
part of the nurse and attendants; and espec- 
ially is this true of children who will put 
their fingers into their months and tear out 
stitches and do all sorts and kinds of things. 

Prognosis of Operation on Hard Palate. 

Where the cleft is not too wide in adults 
it can be closed, and the same is true of 
younger persons, but it should always be 
remembered that voice if it ever becomes 
normal must be made so by training. 

So far as the closure of clefts is concerned 
in young infants it is safe to say that it may 
be accomplished by the Brophy method if 
practiced during the first few weeks of in- 
fantile life with the prospects of having a 
fairly good voice, and with a very small 
mortality as the result of the operation. 

Tension of the 'Tissues. 

There may be a good deal of tension of 
the tissues where the fissure in the lip is 
closed. It would be difficult to say just 
how much tension can be tolerated here, 
but a good deal. It is better, however, to 
have practically no tension even here. This 
may be corrected by relaxation sutures, and 
collodion and gauze dressing after the lip 
has been closed with the sutures. Small 
strips of gauze should be used and the 
greatest care taken to have it thoroughly 
dry before the patient is from under the 

As to the tension in the soft palate, and 
the tissues of the hard palate that have been 
slid over there should be none, or practi- 
cally none, for certainly any great amount 
of tension here will result in the stitches 
cutting into the tissues. Some of this might 
be tolerated, but it is not wise to take any 

risk of this kind. Always be sure that the 
parts are apposed with the smallest amount 
of tension — as I said before there should be 
no tension here. 
Suture Material, and Relaxation Stitches. 

Under ordinary circumstances silk sutures 
are preferable in operations about the mouth 
and palate because they are more pliable 
and less liable to inconvenience the patient. 
In placing relaxation stitches it is wise to 
double shot them, slipping on a shot fol- 
lowed by a second one tightening the last 
which will of course push the first one down 
close into the tissues. The advantage of 
this is if the relaxation stitch should become 
too loose you can push down the shot next 
to the tissues and tighten up this relaxation 
stitch at any time it is desired to do so. 
Malformations of the Mouth and Nose. 

In attempting to correct these defects it 
should ever be born in mind that the great- 
est desideratum is a perfect mouth and nose, 
and in most cases this can be accomplished. 
The operator must bear in mind that nature 
will not help him in correcting any of these 
deformities. There is no such thing as 
"out growing" any defects that are not 
corrected at the time' of the operation, and 
especially is this true of the lip line. If 
there is a "notch" at this point of union of 
the two sides when the operation is com- 
pleted it will always remain a notch — it will 
not fill up. The lip line had better curve a 
little convexly down than concavely up- 
wards. The surgeon should bear in mind 
that the abundant nerve and blood supply 
of the parts will always enable him to do 
almost anything he desires with the lip 
tissue with the assurance that rapid repara- 
tion will follow. In some cases the vertical 
edges of the cleft are thin for quite a little 
distance from the margins. If these edges 
are freshened and united it is almost certain 
that the thinness of the parts will be so 
marked as to make the lip unsightly. In 
such cases the thin edges should be split 
and the skin surfaces united by one set of 
sutures and the mucous membrane by an- 
other, or if the tissues will admit cut off the 
thin parts and unite where the tissues are 
sufficiently thick. 

If for any reason in a given case it was 
thought best to close the lip and leave the 
cleft in the hard palate until a later period, 
I would not hesitate to open up the lip in 
order to secure a better view and better 
opportunities in closing the cleft and subse- 
quently reclose the lip. 



Tubal Pregnancy. 

By \V. P. Whittington, M. D., Asheville, N. C. 

The fertilization and implantation of the 
ovum in any part of the fallopion tube be- 
tween the graoffian follicle and the uterine 
cavity, is what we mean by tubul pregnan- 
cy. We believe that all extra-uterine 
pregnancy wherever found at the time of the 
operation or autopsy, were originally tubal, 
and that their abdominal or pelvic position, 
had been acquired by rupture, or by expul- 
sion through the ostium abdomiuale, known 
as tubal abortion. There is little doubt 
that the ovum may become fertilized in any 
part of the tube; it should not normally be 
implanted and developed outside the uter- 
ine cavity. Tubal pregnancy is usually 
classified according to its location in the 
tube. It is interstital when it occupies 
that part of the tube which is included in 
the uterine wall, isthmic occupying that 
part of the tube between its enterence into 
the uterine wall, and the ampulla. Ampul- 
lar}- situated in the ampulla. Infundibu- 
lar occupying the pavillion. 

When the ovum is fertilized, implanted 
and begins its development in any part of 
the tube; the entire genital tract responds 
to its inflnence. The symptoms of normal 
pregnancy are often found in the vagina, 
the uterus enlarges, its walls becomes thick- 
er, its vascularity is increased and its cavity 
is enlarged. This growth usually contin- 
ues as long as the embryo is alive, but the 
uterus rarely reaches a depth of more than 
five inches. A decidua forms in the uter- 
ine cavity in all cases of tubal prenancy. 
This decidna is rapidly discharged on in- 
terruption of the pregnancy, and if the 
pregnancy should continue without inter- 
ruption until the twelfth week, the decidua 
is gradually thrown off as a sero-sanguiuo- 
lent fluid. There may be a complete cast 
of the uterine cavity thrown off. Some- 
times the hemorrhage from the urine cavity 
is sudden and profuse, and may cease 
almost as suddenly as it began. The oav- 
ary on the side of the impregnated tube 
becomes enlarged and shows a corpus lute- 
um. As soon as the ovum is implanted in 
any part of the tube there is developed the 
membranes usual in normal pregnancy. 
The first effect of this implantation of a 
fertilized ovum in the tube is to cause an in- 
creased vascularity. The muscular fibers 
are at first hypertrophied and the connec- 
tive tissue cells are converted into decidual 

As the development proceeds the tube is 
dilated to such an extent that it loses its 
muscular character, and the gestation sac 

oRead before the ioth District Medical Society 
Hendersonville, N. C , November 5th, 1907. 

is converted largely into connective tissue. 
Unless the tube ruptures the gestation sac 
is enlarged by inflammation and stretching 
of the peritonaeum in such a way as to 
accommadate the developing embryo and 
its membranes. If the pregnancy is not 
arrested by the eighth week the fimbria be- 
comes contracted and inflamed so as to 
close the ostium abdomiuale. If the preg- 
nancy is terminated before the eighth week, 
it is usually by abortion through the ostium 
abdomiuale into the abdominal cavity. 

After the eighth week the termination or 
arrest of development is caused by the en- 
tire rupture of the tube and expulsion of 
the embryo into the abdomiuale cavity or 
pelvis, or by rupture of a vessel on the in- 
side of the tube and hemorrhage into the 
gestation sac in such quantity as to cause 
death of the embryo. In this case if the 
pregnancy is isthmic it is converted into a 
tubal mole. In interstitial pregnancy if 
hemorrhage takes place into the gestation 
sac and the point of least resisteuce is near 
the uterine end of the tube, and this 
hemorrhage into the sac occurs early, 
the contents of the sac may be expelled 
into the uterus and the pregnancy thus fa- 
vorably terminated. 

On the other hand if the pregnancy is 
ampullar or infundibular and the hemorr- 
hage into the sac occurs before the eighth 
week, the point of greatest resistance being 
the ostium abdomiuale, the probability is 
that tubal abortion will take place. After 
abortion or rupture of the tube into the 
peritonaeum or broad ligament the embryo 
may be reimplanted in its new location and 
continue to develop even to maturity. The 
symptomatology of tubal or extra-uterine 
prenancy varies according to the stage of 
its development. The early symptoms 
most commonly resemble those of normal 
pregnancy. There is usually amenorrhea 
of one to three months. It is, however, in- 
terferred with by the expulsion of the uter- 
ine decidua, caused either by rupture of 
the tube or by the natural efforts of the 
uterus to get rid of a foreign or unnecessary 
growth. After the decidua is thrown off, 
if the tube has ruptured and the embryo 
perished, the uterine hemorrhage may con- 
tinue at intervals indefinitely; especially if 
the gestattonsac is near the uterine end of 
the tube and the tube has not completely 
emptied itself. If the tube has completely 
emptied itsell and the embryo conrinues to 
grow in its new location, is established and 
continues indefinitely. Pain is a common 
symptom of tubal pregnancy, and is due 
the injuries resulting to it and the surround- 
ing tissues. The pains are usually inter- 
mittent, owing to the temporary relaxtiou or 
giving away of resistance of the tube. As 


the embryo develops, the pressure becomes fill and there may be many symptoms of 
greater and the pains again occur. If the spurious labor, of a very annoying charac- 
tube is lacerated by this distention to such ter. 

an extent as to allow hemorrhage into the The two most important things in the con- 
peritoneal cavity or between the layers of sideration of tubal pregnancy are diagno- 
the broad ligament, the pain will be accom- sis and treatment. The only way to make 
panied by more or less shock, and evidence a diagnosis is to thoroughly examine and 
of hemorrhage. The patient may recover study every case of pelvic disease that pre- 
from this to again suffer the same or worse seuts itself, and when the diagnosis is not 
condition at longer or shorter intervals, for clearly made by a proper use of all other 
days and even weeks, if not relieved by methods at hand, we should not hesitate to 
appropriate treatment. As stated in anoth- make an exploratory incision. I operated 
er part of this paper, the uterus is some- on a lady sometime ago who had been an 
what enlarged and if the tube has not rup- invalid for twelve months, and who had 
tured, the uterus is movable and occupies a been treated with bromides, tampons and 
normal position. The changes in the color pesseries, without benefit. I knew there 
of the vagina and cervix are not reliable, was a retroversion and that there was 
but after the second month, may be mark- something wrong with the left tube but I 
ed. If hemorrhage has taken place into did not know what. I opened the abdomen 
the abdominal cavity or broad ligament, we and found the fimbria firmlo adherent over 
will have a tumor varying in size accord- the end of the tube and the ostium abdomi- 
ing to the amount and location of the hem- nale closed. There was a small oval tumor, 
orrhage. If the rupture is into the broad the size of pigeon's egg, about the middle 
ligament, the uterus is pushed to the oppo- of the tube, which represented a tubal mole, 
site side, and is sometimes lifted out of the the remains of a blighted tubal pregnancy, 
pelvis. If the hemorrhage is into the ab- The tube was removed, the uterus suspeud- 
dominal cavity the poster or cul-de-sac will ed, and the woman cured. 
be full of clot, pushing the uterus forward The diaognosis being made there is, in 
and lifting it above the pubis. If we are my opinion, only one course to pursue; and 
fortunate enough to make an early diagno- that is to operate. In the earlter mouths, 
sis, before rupture has occured, we will find before the viable period of the child, I 
a tumor of oval shape, varying from the think, there is no dispute as to this plan, 
size of a pigeon's egg up, according to the If the diagnosis is made before the rupture, 
duration of pregnancy. This tumor will the tube and the gestation-sac should be 
appear Pedunculated or in close apposition removed by the abdominal route, or if not 
to the uterus according to its location in removed entirely the sac may be opened 
the tube. It is usually tender on pressure, and cleared of contents and closed. If the 
slightly elastic and more or less movable, tube has ruptured or aborted, the operation 
We may be able to palpate the ovary as a is imperative and the abdominal route is to 
separate tumor on, or close by the tube. be preferred. 

On the occurance of hemorrhage into or Now again referring to the period after 
around the sac on the inside of the tube, the fourth month I do not think we should 
the tumor rapidly enlarges, and often as- delay operation. In doing so we may sub- 
sumes an elongated shape. It looses its ject oue patient to sudden rupture of the 
mobility on account of inflammatory adhe- sac and death by hemorrhage and that too 
sions and becomes very tender to pressure, with but little to gain. Statistics show that 
After rupture into the abdominal cavity very few of the yery fiew, children who are 
inflammatory adhesions occur and the ab- delivered alive ever survive the second year, 
domen becomes hypersensitive. The tumor and that a very far less number arrive at 
formed by the coagula is very sensitive to adult life. There is only one condition in 
digital examination per vagina. Should which I would advise delay and that is 
infection occur, we have an extensive sep- where we do not make a diagnosis until 
tic peritonitis with all its distressing symp- very near the viable period of the fetus, 
toms and results. The question of supreme importance in op- 

After rupture, should the embryo be re- eration in advanced extra-uterine pregnau- 
implanted and continue its growth in the cy is the disposition of the sac and placenta, 
broad ligament or pertineal cavity, the When it can be pedunculated and ligated 
tumor will gradually increase in size and en-mass, this is the proper thing. When it 
more or less pain of an intermittent nature cannot be so ligated, it is probably best to 
continues. The abdomen usually becomes leave the placenta in tact and pack with 
symmetrically enlarged, but often the en- gauze and partly clase the wound until the 
largement is greater on one side. placenta is separated and the sac closes by 

Alter the fourth month, when evidence contraction and granulation, 
of fetal life begin, the movements are pain- The operator will have to use a great 



deal of .judgment and anitomical wisdom 
in the method pursued. Sometimes by lega- 
ting the pelvic and uterine arteuial connec- 
tions the uirculation may be so campletely 
cut off that the placenta can be easily re- 
moved. If the fetus is already dead and 
ation begun it should be as thor- 
oughly removed as possible and drainage 
through the vagina established. In cases 
where the fetus has been dead for a long 
time and occupies the pelvis, an opening 
through the vagina will be most advanta- 
gious and the debris may be removed or 
allowed to drain away through the vagina 
without danger of infecting the peritoneal 

The Position ol the X-Ray Specialist in 
the Field ol Medicine and Surgery.j 

By Dr. A. L. Gray, Richmond, Va. 

The wonderful things promised to the 
world, from the very announcement of 
Roentgen's discovery, by those who first 
experimented with the X-Ray and the 
many erroneous statements of its possi- 
bilities, especially along the lines of treat- 
ment, caused in a few years a very decided 
skepticism among the profession as to its 
real worth. This was not at all unnatural 
and was the necessary sequel to the un- 
scientific reports of cases by men desiring 
notoriety at the expense of establishing 
truths good for all times. 

There are still two distinct classes exist- 
ing in the X-Ray world; the one procures 
an outfit for the impression he may make 
on the minds of patients or prospectives, 
and uses it merely for advertising, as an 
interesting toy, or simply because a com- 
petitor has one and he cannot afford not to 
have one also; the other class consists of 
those who, by careful observation, intelli- 
gent and painstaking investigation, arrive 
at conclusions only after summing up facts. 
< )nly such men as these can become spec- 
ialists in anything. 

The question may be asked why should 
X-Ray work be a specialty? Should it not 
be a part and parcel of the equipment of 
every physician or surgeon? My answer 
would be thai it is a study of itself, suffic- 
ient to occupy more than the entire time of 
any man. 

The ideal X-Ray man should be a phy- 
sicist, an electrician, a photographer, an 
expert anatomist, a pathologist, therapeutist, 
physician and surgeon, and withal, compe- 
tent in the field of forensic medicine. 

The radiologist is often told by his pati- 
ents that they were sent "to have an X-Ray 
pictur e made to find out just what the trou- 

JRead before the Tri-State Medical Association 
meeting at Charlotte Feb. iS, 1908. 

ble is." This expression is about on a par 
with the sending of a tubercular suspect to 
have his chest percussed in order to find out 
whether he has tuberculosis. X-Ray diag- 
nosis requires an examination just as truly 
as does the microscopist examine specimens 
referred to him. Making the picture is the 
easiest part of the work. 

It is essential that the most accurate 
knowledge possible be obtained of the 
nature and capacity of the apparatus used, 
as well as the relative positions of tube, 
parts examined and plates. 

It is sometimes said that the "X-Ray 
picture lied" about a condition. This is 
never true; the belief arises from lack of 
familiarity sufficient to enable a proper 
reading of the negative. Take a case of 
simple transverse fracture of a long bone, 
and it is entirely possible to make a nega- 
tive that will not show a fracture at all or 
one that shows wide separation, though the 
ends may be in almost perfect apposition. 
The negative is a true picture of the exist- 
ing conditions. There is nothing simpler 
than making a radiograph; the interpreta- 
tion of it requires skill. 

There are many cases that show apparent 
injury on the plate when no real injury 
exists. Especially is this true at the epi- 
physeal ends of the long bones of the young. 

Even more skill and special knowledge 
are required in the application of the Roent- 
gen rays for therapeutic purposes. Take 
for example the two skin diseases, lupus 
and chronic eczema: in the former the best 
results are obtained by treating with long 
close exposures carried almost to the point 
of producing a burn of the second degree, 
while the latter requires the mildest stimu- 
lating applications. 

Much and irreparable damage may be 
done by the unskilled use of this powerful 
agent. Different pathological conditions 
require very different modes of treatment. 
That which may be beneficial to one con- 
dition may be very injurious to another. 
Many more reasons may be advanced to 
show the necessity for a most thorough 
knowledge of the equipment, dosage, the 
pathology of the case and rationale of the 

It seems therefore evident that, in order 
to employ intelligently the X-Rays either 
for purposes of diagnosis or treatment, the 
most complete application of one's time and 
talents to this subject is essential. It is a 
study about which every case gives new 
information, and in order to become the 
expert that modern times require, he should 
devote practically his entire time to the 
acquirement of the special skill necessary 
for success. 

There is perhaps 116 field in which the 



medical man may labor that more certainly 
requires that he be possessed of tact and 
that he demean himself ethically toward 
his fellows, than that of X-Ray work. Bad 
surgery is constantly being exposed, and 
unless the greatest care is employed, dire 
results may follow. Often indiscreet com- 
ments may result in damage or malpractice 
suits. Equally true is the reverse with the 
guarded and ethical Roentgenologist. He 
not only can be of value in ascertaining 
the true condition for treatment purposes 
but can furnish the most efficient means of 
satisfying the patient with the results, by 
an ocular demonstration such as is given in 
a good radiograph. It has been my good 
fortune to avert damage suits on numerous 
occasions by a careful X-Ray examination. 
There is perhaps no department of the 
healing art in which the X-Ray man may 
not be found useful. The genito-urinary 
surgeon employs the Roentgenologist to 
locate calculi; the eye, ear, nose, and throat 
men find him useful in locating foreign 
bodies in these organs and in sinus, antral, 
and mastoid diseases, in locating hard tis- 
sue tumors in these and accessory regions 
as well as the treatment of such conditions 
as fall within the scope of X-Ray therapy. 
The obstetrician employs him to determine 
foetal position, presentation, multiple con- 
ceptions and the shape and formation of the 
pelvis of the mother; the gynecologist may 
have him differentiate the denser tumors 
and treat inoperable malignant diseases; 
the stomach specialist may learn from him 
the size and position of the stomach, its 
motor power and also these facts concern- 
ing the intestines; the chest expert finds 
him useful for determining the size, shape, 
and position of the heart, the presence of 
air or fluid in the pleural cavities, thickened 
pleura, consolidation and various evidences 
of incipient tuberculosis, cavities in the 
lungs, aneurisms, enlarged glands and ma- 
lignant tumors in the chest; the brain sur- 
geon has him locate dense growths, ab- 
scesses, or fractures; the internist finds him 
useful in the treatment of diseases of the 
blood forming organs such as leukemia, 
pseudo-leukemia, and many of the fore- 
going diseases mentioned under the other 
sdecialties. In perhaps no other field is 
X-Ray treatment more useful than as an 
adjunct to the skin specialist. There is 
scarcely a single intractable chronic skin 
affection or parasitic skin disease that may 
not be benefited or cured by the proper 
administration of this agent. The uses in 
general surgery are too well known and too 
numerous to admit of discussion. I desire, 
however, to lay special stress on the value 
of X-Ray examinations in bone diseases 
and in joint injuries or affections. It should 

be the rule to have an X-Ray examination 
made for any joint trouble that is the least 
obscure. Perhaps there is no joint condi- 
tion of which there is greater liability to 
error in diagnosis than that of the hip. 
Often does the radiograph reveal disease 
where fracture is suspected, and especially 
is the reverse true. Obscure causes for 
prolonged disability are often made clear 
and imaginary or simulated injuries for 
purposes of financial gain are also often 

There should be in every city at least one 
physician who makes this work his specialty . 
He should have the hearty co-operation of 
the profession about him and should so 
equip himself that, by reason of his accur- 
acy, ethics, and readiness to spare neither 
pains nor patience to add to our far-from- 
complete knowledge of this subject, he may 
render himself indispensable to the com- 

I do not wish to encourage the promis- 
cuous employment of an agent that may be 
so harmful in so many ways in unskilled 
hands. Failure to obtain results when they 
should be expected and especially the pro- 
curing of undesirable results will tend to 
bring into disfavor what should be a most 
potent factor for good. 

Let us work together for the mutual 
advancement of our different specialties, 
for the relief of suffering humanity and the 
world will bless our efforts. 

M2 E. Franklin St. 

Massive Quinine Dosagcin the Treatment 
of Pneumonia, o 

By R. L Payne, Jr., M. D., Norfolk, Va. 

In writing upon the subject of Pneumo- 
nia I feel that I am approaching a subject 
which is near and dear to us all, and one 
which, in spite of its familiarty, presents 
in itself a query that has puzzled our fath- 
ers of medicine for hundreds of years, and 
is destined to prove a mystery peihaps for- 

The pathology of Pneumonia in its three 
stages, together with the popular methods 
of treatment are familiar to you all and so 
I shall endeavor to discuss with you some 
new thoughts, new hypotheses and new 
treatment of this dreaded disease, hoping 
that some of you may become interested 
and in your practice give Quinine Sulphate 
a trial in the treatment of Pneumonia. I 
say a trial, for I feel that in spite of my 
own conviction, born of a limited experience, 
the Quinine treatment of Pneumonia is still 
a proposition of doubtful utility and war- 
ranted only by results obtained in the expe- 

oRead before the Seaboard Medical Association, 
Dec. 16th, 1907. 



rience of a few men. So far it has been 
simply a matter of accepting the radical 
statements of those using this treatment 
without any research work on the subject, 
practically without theories and with noth- 
ing to justify our giving it atrial, except 
results obtained. Still we might stop right 
here and agre that to relieve and curse our 
patient in the quickest possible way is our 
chief intent and purpose, no matter how 
accomplished, but I feel that this is an age 
when we should not accept every theory 
advanced, and so I hope that some of you 
wili go further than to merely give this 
treatment a trial and endeavor by your best 
efforts to work out and explain the why and 
wherefores, for in so doing only will the chief 
merits and intelligent use of Quinine in 
Pneumonia be brought to light. 

In reviewing the literature I find Juergen- 
sen first recommending Quinine in five and 
ten grain doses in Pneumonia in 1879, and 
as far back as 1875, A. L. Loomis advocat- 
ed the use of Qunine, giving 25 grains at 
one dose and 15 later, or, as he says, the 
total 4(i grains can be given at a single 
dose. Nothing, however, of much note 
appeared concerning Quinine in Pneumo- 
nia until January, 1905, when Galbraith, 
in the Journal of the American Medical 
Association, brought to our notice the value 
of large and repeatedidoses of Quinine in 
the treatment of Pneumonia, and in this 
paper he reported 50 cases successfully 
treated and discussed his original methods 
of dosage. This was a paper of great worth 
on account of its originality, and if Qui- 
nine proves to be as useful in Pneumonia 
as our limited experience has shown, the 
profession owes a big debt to Galbraith, the 
pioneer in this work. 

In brief the treatment consists of the 
administration of 40 to 80 grains of Qui- 
nine Sulphate at one dose, followed in three 
hours by 30 or more, and then starting 
with Tincture Ferric Chloride minus 15 to 
20 every three or four hours. The second 
day, and even the third, these doses are 
repeated, and if at that time the patient is 
noi considerably better or the crisis has not 
taken place, then ten grains of Quinine are 
given every three or four hours. Of course, 
these are adult doses and the doses for chil- 
dren should be proportionate, but you 
would be surprised to know what large 
doses of Quinine a child suffering from 
Pneumonia can take without showing any 
signs of cinchonism of depression. 

During the winter and spring of 1906 I 
saw and treated twenty -two cases of Pneu- 
monia by this method without a single 
death. Of 1 his number sixteen were cases 
of typical lobal Pneumonia; four alcoholic, 
with accompanying delirium in all, and in- 

volvement of both lungs in two, and two 
cases were post-operative, or ether Pneumo- 
nia. Last w r inter I treated seven cases suc- 
cessfully, two of which were post-operative 
and one lobular in type. This fall I have 
had one case treated with massive doses of 
Quinine, whtch had a pseudo-crisis on the 
morning of the third day and a real crisis 
on the fourth. Thus 1 have to report to 
you 30 cases treated by this method, with- 
out a single death, but right here 1 might 
say that I think my first few cases did 
equally as well as my last ones, even though 
my experience was nil. 

Still with each case I feel that I have 
learned something more of this treatment, 
and I wish to report to you briefly four 
cases representing different types of the 
disease and discuss some of my observa- 

Case 1. Alcoholic Pneumonia, J. C, — 
male 26 — wife says he drinks constantly 
and for the past two weeks has been drunk 
most of the time — one week ago was taken 
sick and on admission to hospital, April 1st, 
1906, was very delirious and seemed to be 
suffering from a pronounced toxaemia — 
temperature 105, 1-5 — pulse 126 — resp. 60 
— exceedingly restless, with wild staring 
eyes, short, restrained cough at frequent 
intervals, and tremors so exaggerated that 
wrist and ankle cuffs had to be used. 

Physical examination revealed signs of 
complete consolidation of entire left lung, 
with harsh breathing over base of right 
lung. He was given at once calomel, 
grains % every one-half hour up to three 
grains, and at nine p. in., two hours after 
admission, 50 grains of Quinine Sulphate 
in solution with muriatic acid. At twelve 
m. 30 grains more of quinine were given 
and minums 20 Tincture Ferric Chloride, 
every three hours, ordered. 

April 2d, 1906, — Delirium very much 
exaggerated having passed a sleepless 
night — coughing with great deal of pain — 
temperature 102 4-5 — pulse 110 — resp. 50. 
At ten a. m., gr. 40 of Quinine Sul. were 
given and at 3 p. in., 30 more grains were 
administered. At six p. m. the tempera- 
ture was 102 — pulse 100 — resp, 52, and de- 
lirium and toxaemia seemed to have lessen- 
ed. Physical signs remained about the 
same as one admission. 

April 3rd, 1906. Delirium absent — pati- 
ent entirely rational — coughing with diffi- 
culty and raising bloodly sputum — temp. 
102)4— pulse 96— resp. 20. Quinine Sul. 
gr. ten were ordered every three hours. 
Patient said he was not deaf at all and that 
his ears were not ringing, but complained 
of a bitter taste and that water and coffee 
tasted bitter. This ten grains every three 
hours was kept up until the morning of the 



5th, when his temperature fell to normal 
and never rose again. On this day of crisis 
he coughed freely for the first time and ex- 
pectorated rusty sputum to the amount of 
a small teacupfull. The next day the spu- 
tum hardly measured 3 tablespooufuls, and 
the day following was nearly nil. This 
scarcity of sputum in the stage of resolu- 
tion I especially call to your attention, and 
will speak of it more at length later on. 
Counting one dose on the morning of the 
5th this patient was given 320 grains of 
Quinine in a period of four days. 

Case No. 2. J. Mc. male child, age 3 
years — mother said child had been sick 
three days with cough and high fever. On 
admission, April 6th, 190t>, child's temp, 
was 104 — pulse 150 — resp. 48. An exami- 
nation revealed flatness and bronchial 
breathing over entire upper lobe of right 
lung. Two grains of calomel and soda 
were given at a single dose, and at three 
p. m., two hours after admission, 15 grains 
of Quinine Sul. At six p. m., ten grains 
more of quinine were given and ninums 8 
Tincture Ferric Chloride every 4 hours order 
ed. I saw the child repeatedly up to mid- 
night of this date, and at no time did he 
show signs of excessive nervousness, rest- 
lessness or rash, such as we frequently see 
in children from too much quinine. At this 
time temp. 103, pulse 140, resp. 46. 

April 7th, 1906, temperature, pulse and 
respiration about the same, child perfectly 
quiet and slept most of the night. I could 
not determine whether his ears were ring- 
ing. At nine a. m. he was given 15 grains 
of quinine and three hours later ten 
grains more. At this time, noon, his 
was temperature was 103, pulse had drop- 
ped to 106 and resp. 46. He showed no 
symptom of too much quinine but seemed 
somewhat deaf when spoken to in a sub- 
dued voice. At six p. in., he did not seem 
at all deaf, noticed every time he was ad- 
dressed and coughing without much effort. 

April 5th, 1906, condition about same 
except temperature was 102, pulse 105, 
resp. 47. He was not given quinine on 
this day, hoping the crisis would occur. 

April 9th, 1906, temperature 102, pulse, 
106, resp. 48. Child was breathing with 
difficulty but coughing freely. At 12 noon, 
15 grains of quinine were given, and at 
three p. m., ten grains more were ordered. 
At five p. m., two hours later, crisis had 
occurred; temperature normal, pulse 96, 
resp. 38, child was resting quietly, did not 
seem deaf the least bit and his recovery in 
one week was uneventful. No sputum was 
ever noticed in this case, and if present was 
swallowed as fast as coughed up. 

( ase No. 3. Post-operative or either pneu- 
monia — Mrs. N., female age 29. Admitted 

to hospital May 2d, 1907, suffering with bi- 
lateral pustubes. I operated on her for 
this trouble, removing too large pus sacs 
from the pelvis, the operation lasting about 
one hour. She did very well until the even- 
ing of the second day following operation 
when she was seized with a severe chill, 
pain in her right side and her temperature 
rapidly rose to 103, pulse to 120, and resp. 
to 46. I examined her lungs six hours 
later and found tubular breathing over the 
middle and lower lobes of the right lung. 
At this time she seemed to be very much in 
distress and her lips and finger tips were 
very much cyanosed. A diagnosis of ether 
pneumonia was made and fifty grains qui- 
nine sulphate immediately administered in 
capsules. These capsules were vomitted 
in ten minutes, and thirty minutes later I 
gave her 50 grains in solution with muriatic 
acid, which was retained. Three hours 
later, at 12, midnight, 40 grains more of 
quinine were given and tincture Ferric chlo- 
ride'minums 20 every three hours ordered. 
At nine a.m. the next morning May 5th, 
her temperature had fallen to 100, pulse 92' 
resp. 38. She was resting quietly and said 
she felt so much better than the night 
before. Said her ears were ringing 
slightly last night but not at all now. 
At this time the physical signs were fully 
developed and she was coughing frequently 
but raising no sputum. She was given 40 
grains of quinine and in three hours 30 
grains more. Six hours later she com- 
plained of no tinnitus and her pleuritic 
pain had entirely disappeared under the 
use of two ice caps. 

May 6th, 9. m. Temperature normal, 
pulse 82, resp. 28. Examination revealed 
solidification of midnle and lower lobes of 
right lung with a fair number of moist 
rales. The patient expectorated a small 
amount of rusty sputum the next three days 
but her temperature never rose above nor- 
mal and her recovery was uneventful. 

My first experience with this treatment of 
pneumonia was had in conjunction with 
Dr. T. E. Mendenhal, at that time my col- 
league in hospital service, and I feel that 
our success from the first was largely due 
to his precistou and keen ability of obser- 
vation in those first dozen cases. On be- 
ginning this paper I wrote to him asking 
for his later experience with quinine in 
pneumonia and in reply he said he had 
treated nine cases with one death. At the 
same time he cited a case I wish to include 
in this paper. Dr. Mendenhal, who does a 
large practice in the mining section of Beav- 
erdale, Penna. writes as follows : 

"inow have a patient which well illus- 
trates my line of cases. The men here 
work in the miues with litttle clothing, get 



warm and come out and walk a half mile in 
the cold. The man in question walked home 
in a snow storm and at one o'clock p. m. 
had a severe chill followed by a tempera- 
ture of 104. I saw him at 2a.m. and found 
the whole of theright lower lobe congested 
with all the physical signs of the first 
stage. He had a high tension pulse and 
very much accentuated second heart 
sound. In order to be sure of beginning 
pneumonia I simply gave a cathartic and 
aconite until morning, and at S a. m. all 
the physical signs were present. I then 
gave 80 grains of quinine sulphate and 
three hours later 40 grains more and started 
Tincture Ferric Chloride miliums, 15 every 
three hours. His pulse dropped from 108 
to 82 and temperature from 103 2-5 to 100 
by 4 p. m. He remained about in this con- 
dition for forty-eight hours when his pulse 
rose to lno and temperature 102. I gave 
him 4o grains of quinine and in three hours 
30 more with results of first dose. He then 
developed a very productive cough which 
lasted three days and on the 8th day he was 
sitting up. To-day is his 12th day, and when 
I went to see him he was at the dinner table 
with the rest of the miners." 

To me this case is a plain and forcible ex- 
ample of what quinine will do in pneumo- 
nia and I feel sure that this attack was prac- 
tically aborted by the early and massive 
doses of quinine. In my limited experi- 
ence I have found this treatment of infi- 
nite more value in Frank Cobar pneumo- 
nia than in the broncho or lobular type 
where the good effects are not nearly so 
marked or the duration of the disease so 
much shortened. But I think it is the rule 
in most cases of broncho-pneumonia that 
there is usually present a mixed infection 
and this thought brings us to the vital ques- 
tion of how quinine acts in pneumonia. 

Whether it has a specific action in 
pneu mococccic infection and not so in 
infection from other organisms? Whether 
it heli is to neutralize the pneumo-toxin 
chemically by the so-called comple- 
mental or amboeeptal action, or does 
it stimulate an active immunity by its ac- 
tion on the tissue cells or bacteria? If on 
the latter, is its action of an agglutinating 
or bacteriolytic nature ? Most particularly 
am I interested in the action of quinine on 
the blood cells and blood plasma and here 
I believe research will do most toelucidate 
our questions. Pysiological research has 
long since told us that quinine checks the 
formation of leucocytes and inhibts their 
ameboid movements and from this view we 
might well argue that quinine, havin g this 
action, would tend to maternally limit ex- 
udation and thus yield a favorable result. 
This may be more or less true but in nearly 

all of my cases careful counts were made 
of the wdiite cells with the result .hat from 
one to six hours after the exhibition of 
large doses of quinine the leucocytes inva- 
riably increased from one to three thous- 
and. Though this is a small increase still 
with other facts to consider it ma)' be of 
the greatest importance. I am fully assur- 
ed that there is some direct chemical action 
on toxin and cocci from the fact that we 
don't get any cinchonism and the reaction 
of the patient for the better is so pronounc- 
ed shortly after administering the quinine. 
Quinine undoubtedly stimulates the heart, 
giving a slower, softer pulse, and at the 
same time materially increasing the peri- 
pheral circulation, for the drop in tempera- 
ture and pulse accompanied by a freer ac- 
tion of the skin and increased comfort of 
the patient all tend to justify this conclu- 
sion. It is the rarest thing to get chincho- 
nism even after such massive doses of qui- 
nine in pneumonia, and I recall a patient 
wdio was given 100 grains by mistake for 
an order of 50, but who complained wery 
slightly of tinnitus and showed absolutely 
no bad symptoms. Whenever deafness and 
tinnitus does occur it invariablo disappears 
in six or eight hours and in my recent cases 
I don't notice it much but rely more on arise 
in pulse as a guide to giving more quinine. 
The question of cinchonism depends largey 
on the degree of the disease, that is the de- 
gree of intoxication, and I recall several 
cases where the patient was seen a short 
time after the initial chill and quinine giv- 
en with a resulting deafness; whereas a day 
or so following when the toxenia had in- 
creased even larger doses of quinine were 
ingested without the least signs of cincho- 
nism. This seems beyond a doubt to in- 
dicate some neutralizing action of the spe- 
cific toxin on quinine or vice versa, for 
before bacteriolysis has liberated the intra- 
cellular toxic substances into the tissues of 
the body we get the signs indicative of so 
much quinine in the circulation, causing 
certain symptoms. As the toxins increase 
there is supplied the so-called chemical 
complement and cinchonism is found want- 

Right along with these thoughts the 
method of administering quinine is a ques- 
tion of some interest for most probably its 
absorption into the tissues is depent largely 
on its solubility. Quinine being insoluble 
except in an acid medium it has occurred 
to me that, when given iu capsules, per- 
haps only enough acid is present at one 
time in the stomach to dissolve a portion, 
say half, of these massive closes and as a 
result we don't get an excessive physiologi- 
cal action of the drug. With this in view 
I decided to exhibit my quinine in aqueous 



solution with hydrochloric acid and in one 
or two cases I thought the action of the drug 
was more decided but the results were hard- 
ly sufficient to warrant my especially advo- 
cating this measure. In the cases reported 
you will recall the fact-that I remarked on 
the small amount of sputum present and 
this phenomena I have watched with most 
careful scrutiny in all my cases. I find 
that the rusty sputum is invariably late in 
appearing, always scanty and disappears 
in from one to three days. The profuse 
mucopurulent sputum, so conimom in the 
stage of resolution, is also either very scarce, 
or, as I have observed, in several cases, 
practically wanting. I have watched this 
sign even from my first ca6es and I didn't 
know any one had ever made this observa- 
tion save myself, but I find on reviewing 
Galbraith's original article that he writes 
as follows : "in quite a number of recent 
cases I have noticed that the rust}' sputum 
has been delayed until the third or fourth 
day of the disease and continues only one 
or two days, probably due to a mixed in- 
fection or the treatment." 

Now to me the explanation of this phe- 
nomena offers more chances towards the 
solution of how quinine acts in pnemonia 
than any other channels of research. Un- 
questionably the leucocytes play the most 
prominent hand and I believe here quinine 
exerctses its most important action. Many 
theories have been advanced to explain the 
various types of immunity to the invasion 
of pathogenic bacteria but all was chaos 
until Metchnekoff demonstrated to us 
the resistant and destructive energies pres- 
ent in the leucocytes to bacteria. The fact 
that quinine does inhibit the ameboid move- 
ments of the white cells ma}' contribute 
largely towards the deceased exudation and 
consequent lack of sputum, but I feel sure 
that phagocytosis plays a more powerful 
hand in bringing about these results and 
that quinine not only stimulates phagocyto- 
sis but has some action direct or indirect on 
the pneumococci. In order to produce bac- 
teriolysis of the ingested organisms and rob 
them of their toxic products, enzymes are 
formed in the protoplasm of the the leucoc- 
tes and probably qutnine in some way stim- 
ulate this formation. Inmost of my cases 
I have made an especial study of the white 
cells with results that may cast some light 
on the subject. Smears were made both 
before and after giving quinine, these pre- 
parations stained similarly and comparative 
study made of the white cells. Six or 7 hours 
after giving quinine the leucocytes appeared 
somewhat swollen and the protoplasm con- 
tained granules, fragments of bacteria and 
debris much in excess of the stained prepa- 
rations before giving the quinine. This was 

demonstrated by repeated preparations. I 
regret that no definite count of the con- 
tained bacteria was made or possible index 
estimated, for this would add materially to 
the last observation. Now we might argue 
that anything that tends to increase leuco- 
cysis would increase this phagocytic action, 
but sincequinine increases the leucocytes 
very slightly, if any, and probably not all, 
we must turn our attention towards the bac- 
teria. Believing that phagocytosis is in- 
creased after giving quinine in large doses 
it seems perfectly tenable that this increas- 
ed phagocytosis is dependent on quinine 
circulating in the blood and tissue juices. 
In other words, we have present a chemical 
substance which acts directly or indirectly 
on the bacteria, sensitizing them and ren- 
dering them more digestible. Thus I find 
myself face to face with the opsonic theory 
and it seems reasonable to believe that qui- 
nine increases the opsonic power of the 
blood, providing we accept the theory that 
an opsonin is nothing more than a chemi- 
cal substance circulating in the blood and 
tissues and combing with bacteria to render 
them more easily digested and destroyed by 
the leucocytes. 

I have failed to mention the fact that, 
whenever possible I always use ice caps 
over the inflamed lung and I don't believe 
anything will relieve the pain of an accom- 
panying pleurisy so quickly or efficiently 
as this agent. The death'ratio of pneumo- 
nia is recorded by most authorities as rang- 
ing from 20 to 40 percent., but men using 
this quinine treatment place the mortality 
at about two percent. So far in 3o cases I 
have not had a single death. In closing 
let me urge you not to approach this treat- 
ment timidly and with small doses of qui- 
nine. Don't wait until bccteriolysis has 
distributed a lethal dose but give your qui- 
nine in large doses from the outset of the 
the disease and I believe your results will 
be in accordance with those already report- 

Sarcoma of Colon. : 

By Dr. CM. Strong, Charlotte, N. C. 

Sarcoma of the intestines is rare, especi- 
ally of the colon. I have been able to col- 
lect only sixty cases. Twenty-four of these 
were in colon, and eight were in children, 
and only four of these in the large intestines. 
These statistics were mostly compiled by 
Krundat, of the Vienna General Hospital, 
up to 1904. Since then only a few cases 
have been collected, and most of these are 
from foreign authors. Being a rare disease, 
a history of it might be of interest. 

1st. Etiology, like that of cancer in geu- 

*Read before the Tri-State Medical Association 
meeting at Charlotte February 18, 190S. 



eral, is merely speculative, but many eases 
have had trauma, which may be the excit- 
ing cause. This is also true of sarcoma in 
other localities. 

2nd. Pathology; Sarcoma, being of the 
connective tissue group, originates in the 
submucus layer of the intestines, extending 
next to the muscularis, and last to the 
mucus, and rarely involves the serosa, which 
is the opposite way in which 'carinoma 
spreads. The most common seat of sarcoma 
is jejunum and ileum, while that of carci- 
noma is the duodenum near stomach and 
large intestines. 

Metastasis, general and local, is less fre- 
quent in intestinal cancer than in any other 
organs. In intestinal sarcoma, general 
metastasis is more frequent than carcinoma, 
and the most frequent sites are the lungs, 
liver, and spleen. Local involvement is 
mostly confined to the intestine and mesen- 
tery, and as the serosa is rarely involved, 
we don't have the tying together of viscera 
we have in carcinoma. Sarcoma is propa- 
gated through the blood channels, while 
carcinoma is through the lymphatics, hence 
sarcoma is a more general infection. Sar- 
coma is probablv a more compact segrega- 
tion of cells, with less infiltration of sur- 
rounding tissues than carcinoma, hence 
recurrence in loco after excision is less 
likely. This theory is borne out by statistics. 
These facts explain the differences in the 
early symptoms, as will be noted later. 
Sarcoma occurs in two forms, the round cell 
and the adeuo sarcoma. The spindle cells 
variety has been only found a few times in 
the intestines. 

The lumen of the gut is rarely narrowed 
in the first stages, while this occurs early in 
carcinoma. They grow very rapidly, but 
rarely involve the peritoneum, except as an 
irritant, which causes the early ascites. 
Vomiting is not common as in carcinoma, 
because there is no early obstruction. 

Spreading through the medium of the 
blood channels, we find early blood dys- 
crasia, emaciation, and metastasis. Symp- 
toms are obscure. The general symptoms 
manifest themselves early in emaciation 
and so-called cachexia, while there are very 
few local ones. In carcinoma we have the 
local symptoms first and general later. The 
most pathognomonic symptoms of cancer 
of the intestines of all kinds is the presence 
of a mass and ascites. 

Pain in sarcoma is not prominent until 
obstruction takes place, the serosa not being 
involved. Blood in feces is not common, 
the mucosa not being involved. Both these 
symptoms are common in carcinoma. 
< (Instructive symptoms come on late, and in 
some cases not at all, the cases dying from 
general infection, with very little local 

manifestations. Very little disturbance of 
digestion is noted as in carcinoma. Most 
of cases occur under 30, while most cases 
of carcinoma occur after 30, though excep- 
tions are found in both cases. 

The most pronounced symptoms are rapid 
emaciation, with a movable mass in abdo- 
men, with ascites. Most cases show tem- 
perature rise, while in carcinoma it is usually 
sub-normal. This is due to the general in- 
fection of sarcoma. 

Diagnosis has rarely been made before 
section or autopsy. Rapid emaciation and 
cachexia without appreciable cause in a 
patient under 30, and the presence of mass 
with ascites should warrant us in making 
probable diagnosis of sarcoma of intestines. 

Prognosis without operation is death with- 
in ten months. With operation, 57 per cent. 
of cures have been reported, making the 
prognosis better than that of carcinoma. 
Of course, the amount of gut involvement 
and general infection affect the prognosis. 
Treatment is removal by resection. 

Report of Case — Mary R., aet. 5, was 
brought to the Good Samaritan Hospital 
eighteen months ago, with this history: 
Family history good, and own history six 
months prior was good. At that time she 
began to lose flesh, and became yellow with- 
out any cause. Two months after a mass 
was noted in the right hypo-gastrium, with 
ascites. There was no pain or digestive 
disturbances, appetite fairly good, bowels 
regular. The swelling and mass increased 
paripassu with the emaciation and weak- 
ness, until she became a skeleton, with a 
large abdomen, but no untoward symptoms 
occurred until three weeks prior to admis- 
sion, when obstructive symptoms appeared 
until seven days before admission, when the 
bowels refused to move after large doses of 
purgatives and enemas were used. Sterco- 
racious vomiting and fearful pains occurred, 
with enormous distention of abdomen. Two 
davs before admission the pains suddenly 
ceased, also vomiting, but pulse and tem- 
perature went up, and on admission the 
pulse could not be counted, temperature 
102, and abdomen distended, and dull, and 
general appearance of extreme gravity. 
The diagnosis was made of a ruptured ap- 
pendix with general peritonitis, and an 
operation, more as a dernier resort without 
any hope at all, was advised, and done. 
Very little ether was used, as she was almost 
insensible of pain. On opening abdomen, 
fluid gushed out, composed of liquid pus 
and feces, a tumor presented size of double 
fist attached to the bowel all around, involv- 
ing only the mesenteric attachment. At 
the proximal side, a rent in the colon was 
found large enough to admit the thumb, 
which was caused by the purgatives, I 



believe, and occurred two days prior, which her period three months, or thereabouts, and 
accounted for the alleviation of vomiting regarded herself pregnant. After slowly 
and pain. The tumor, with about four and recovering from the shock and pain there 
a half inches of the colon, was resected and was no special trouble for several months, 

eud to end anastomosis (Mayo method) 
with a Roosevelt clamp was done, cavity 
washed out with hot saline, two large tubes 
(on account of infection) introduced in 
each angle of wound, with two through and 
through silk worm sutures between, intra 

when she noticed an enlargement in the 
right lower abdomen and consulted a phy- 
sician, who treated her for some time for an 
abdominal tumor. 

Examination. — Temperature one hundred 
and two degrees, respiration hurried, pulse 

venous infusion used. She was put to bed quick and feeble. Her face was flushed 

practically dead. However, she reacted, 
and bowels moved on the fifth day from oil 
per orum and rectum, the tubes withdrawn. 
Left hospital on fourteenth day. No gauze 
was used. And is now, eighteen months 
after, seemingly well and growing. The 
microscopic findings by competent patholo- 
gist showed the growth to be a round cell 
sarcoma, involving the lumen of colon, and 
its attached mesentery. 

This case emphasizes the importance of 
early operations in obscure abdominal dis- 
ease, as the percentages of permanent cures 
are greater in intestinal cancers than else- 
where, and of course the earlier the better. 

1st. The avoidance of strong purgatives 
in obstruction of bowels. 

2nd. The value of operation even in an 
apparently moribund patient. 

and she had an anxious expression. The 
abdomen was large, non-symmetrical and 
sensitive, particularly over the right lower 
portion. She often vomited after taking 

Pelvic Examination. — This examination 
revealed a large and hard globular mass 
very low in the right iliac fossa, uterus was 
high in the pelvis, slightly enlarged, soft to 
the feel and dilated so that the index finger 
could be easily carried to the internal os. 

Sexual History. — She menstruated early, 
and was normal in this respect during her 
single life. She married about eighteen 
years of age, and had four children at term, 
no miscarriages, and her labors were normal . 
She never had any specific disease. 

Treatment. — Operation was performed 

^rd." The wonderful recuperative powers two da Y s after she was admitted, and upon 

opening the abdomen in the middle line 

between the umbilicus and the pubis, it was 

found that the peritoneum was strongly 

adherent to what proved to be the placenta, 

which, though gently handled, gave way, 

and was instantly followed by the most 

profuse out-pouring of blood that I have 

ever witnessed from the abdominal cavity. 

The child, a large monster, in the seven 

and a half month of life, was as quickly as 

possible delivered, the cord cut short, and 

_ . the cavity packed with gauze that had been 

Eciopic Geslation.t steeped in hot water. The hemorrhage soon 

By John W. Dillard, M.D., Surgeon Hygeia Hos- ceasea ana the incision was dressed as an 

pital, Lynchburg, Va. open wQund The shock> however> was so 

Ectopic gestation consists in the develop- profound that the mother never reacted, 
ment of the ovum external to the uterine dying about four hours after the operation, 
mucus membrane, and the variety that I The placenta was strongly adherent to 
desire to report is that commonly known as the peritoneum and intestines. During the 
secondary abdominal pregnancy, primarily operation normal salt solution at a tempera- 
tubal. ture of one hundred and ten was kept con- 

History. — On October 29th, 1907, Mrs. stantly flowing into her vessels by hypo- 
Try, of Ohio, married, aged thirty-six, was- dermoclysis and other cardiac stimulants 

>f end to end anas- 

or the child 

4th. The efficiency 

5th. The value of complete drainage with 
out gauze in general infection. 

Boas. Diseases Digestion. 

Nothnagel Encvclopedia. 

Read ." 

Senn. Surg. 

admitted to the Hygeia Hospital in a much 
distressed condition. While traveling she 
was taken suddenly ill with an intense pain 
in the lower abdomen, most marked on the 
right side. Shock was severe and she be- 
came faint, being unable to travel. Her 
journey had to be discontinued, as this con- 
dition lasted several davs. She had missed 

tRead before the Tri-State Medical Association 
meeting at Charlotte February i8, 1908. 

were used hypodermatically, but to no 

Remarks. — My rule has been to operate 
by the abdominal route whenever this con- 
dition is diagnosed, or even strongly sus- 
pected, regardless of the placental bruit, or 
of the period of pregnancy, believing that 
the dangers dependent on a continuation of 
an abdominal gestation make it unwise to 
delay the operation until the fetus dies that 



the placental circulation may become oblit- 


1 . This was the fifth conception. 

2. ( >nly two years since patient was de- 
livered of last child. 

3. Patient had never had symptoms of 
infectious or inflammatory disease of any of 
the pelvic organs. 

4. Never had subjective symptoms of 
pregnancy prior to the fifth month. 

5. The menstrual period was delayed as 
in a normal pregnancy. 

6. Bupture occurred into the peritoneal 
cavity and notwithstanding patient had no 
treatment at the time mother and child both 

7. The appearance of physical signs in 
this case must have been very late. 

8. She had passed the seventh and a half 
month of her gestation with a large living 
child in the peritoneal cavity. 

Presidential Address- \ 

By Dr. Stuart McGuire, Richmond, Va 

(icnt Ic men of the Tri-State Medical Associa- 
tion of the Carol inas and Virginia: 

The honor of being chosen President of 
this Association was unexpected and un- 
deserved. I find it difficult to express my 
gratitude to my friends in words, but I have 
tried to show my appreciation of their par- 
tial kindness in action, by an earnest and 
continuous effort since the day of my elec- 
tion to make this meeting of the Association 
one of the most successful in its history. 
In this work I have had the active assist- 
ance of many of its members, but especially 
must be mentioned the enthusiastic, untir- 
ing and efficient co-operation of its secretary, 
Dr. J. Howell Way, to whose energy and 
ability must largely be attributed the results 
which have been achieved. 

Our effort has been to accomplish three 
objects: first, to arouse an enthusiasm 
among existing members which would cause 
a large attendance at this meeting; second, 
to secure a list of papers which would con- 
stitute an attractive program; and, third, to 
present the advantages of the Association 
in a way which would induce good men to 
apply for membership. How well we have 
succeeded cannot be determined until after 
the adjournment of this meeting. We have 
every reason, however, to expect an attend- 
ance which will break all previous records. 
There is every promise of the addition of an 
unusually large number of names to the list 
of our members; and the preliminary pro- 
gram which has been published and distrib- 

fRead before the Tri-State Medical Association 
meeting at Charlotte February iS, 1908. 

uted will bear comparison with that of any 
similar organization in the country, in point 
of number of papers, variety of subjects, 
and standing. and ability of authors. 

During the past year, by correspondence, 
personal interviews and speeches at county, 
district and State Societies, the Tri-State 
Medical Association has been called to the 
attention of the profession of the two Caro- 
linas and Virginia in a way which will not 
only result in temporary good, but will con- 
tinue to bear fruit for years to come. The 
time I have personally given to this work 
has been a labor of love, and the only duty 
imposed upon me by my office which I have 
undertaken with reluctance is that of pre- 
paring and delivering an annual address as 
required by our Constitution. We live in a 
prastical age, and the President of such a 
body as this should be an organizer, not an 
orator. I fully agree with Dr. Kollock, 
who said at our third annual meeting, that 
a presidential address has ceased to be use- 
ful or necessary, is a waste of valuable time, 
and is a custom which should be discon- 
tinued. Nevertheless, I set myself to the 
task and spent considerable time in reading 
what had been said upon similar occasions 
by the presiding officers of this and other 
Associations. 1 found that there were three 
lines open to me — historical, philosophical 
and scientific. I determined to write on a 
professional subject, and prepared the rough 
draft of a discussion of the most recent 
views of the pathology and treatment of 
surgical shock. At the last moment I have 
thrown this aside, as a crowded program 
furnishes a repletion of technical papers, 
and I will content myself with a brief re- 
view of the history of the Tri-State Medical 
Association, in order that the new members, 
not familiar with its past, may intelligently 
help to shape its future. 

The organization of the Society was con- 
sidered for some years before it was actually 
accomplished. It was felt that it would be 
both pleasant and profitable for the mem- 
bers of the medical profession in Virginia, 
North Carolina and South Carolina to be 
brought together and to learn to know each 
other better, since in every other way the 
interests of the three States were closely 
identified by location, social ties and com- 
merce. As a result, a few representative 
men met at Virginia Beach in August, 1898, 
and appointed a Committee on Organiza- 
tion. The first meeting of the Association 
was held in Charlotte, N. C, in January, 
1899. Dr, W\ II. II. Cobb, the presiding 
officer, said in his address: "It is eminently 
appropriate that the permanent organization 
and first regular meeting of this Association 
should be held in Charlotte, honored as the 
birth place of American liberty," and I en- 



dorse his words and add that it is a happy 
coincidence that we meet again in Charlotte 
to celebrate our tenth anniversary, and to 
show to the world by our number, our 
strength and our work that the wisdom of 
our founders has been fully justified. 

It is also a reason for congratulation that 
the arrangements for our comfort and enter- 
tainment on this occasion are in the hands 
of a Committee of which Dr. Edward C. 
Register is Chairman, a position he occu- 
pied and so successfully filled when we met 
here before. 

The first few years of the life of the Tri- 
State Medical Association were precarious 
and full of anxiety for those responsible for 
its existence. The State Medical Societies 
were jealous of it, despite the fact that 
affiliation with them was a prerequisite to 
membership in it. It was charged that 
various cliques, rings, specialists and pro- 
fessors promoted its interests for selfish 
purposes, and many who at one time had 
been enthusiastic members became luke- 
warm or antagonistic. During this period 
there was fortunately at the head of the 
affairs of the Association a man of unques- 
tioned character, of undaunted courage, of 
ability, tact and resourcefulness. If any 
one can claim the credit of being the founder 
of the Tri-State Medical Association, it is 
Dr. W. H. H. Cobb, of Goldsboro. 

The early dangers referred to having been 
safely passed, the Association has grown 
and developed in reeent years, especially 
under the administration of two of its 
Secretaries, Dr. R. K. Hughes, of Laurens, 
S. C, and Dr. J. Howell Way, of Waynes- 
ville, N. C. At present, without counting 
new fellows who will be elected at this 
meeting, is has over 230 members, and this 
after eliminating the names of nil old mem- 
bers who have not paid dues for more than 
one year. The personnel of the Society is 
of high order, as its members represent the 
best and most progressive element of the 
great State Associations of the two Caro- 
linas and Virginia. The annual sessions 
of the Tri-State Association have been free 
from political struggles, personal contro- 
versies or ethical discussions. The papers 
read have been of great scientific value, 
and their discussion, while dignified, have 
been sharp and vigorous, thus serving to 
make them more impressive and instructive. 

Some of the profession claim that there 
are too many medical societies — I do not 
believe this is true, but if such is the case, 
the Tri-State will continue to live even if 
tested by the cruel law of the Survival of 
the Fittest. Attendance on medical socie- 
ties is a matter of custom, and doctors 
should get the habit. It is a fact that the 
busy and successful members of the pro- 

fession are the men who are the most regu- 
lar in attendance at county, State, and 
National Medical Associations. It is reas- 
onable to suppose that the duties and re- 
sponsibilities they leave at home are heavier, 
and that the value of the time they lose 
from work is greater, than would be the 
case with their less successful professional 
brother. This condition can only be ex- 
plained by the fact that it pays to attend 
meetings such as this one. The advantages 
are so many and the benefits so various and 
divergent that it is impossible to tabulate 
them, and the time at my disposal is too 
short to elaborate them. It pays a man to 
help make the session of a medical society 
a success because of the influence the meet- 
ing exerts on the community in which it is 
held, educating and stimulating the local 
profession and advertising to the laity that 
Medicine is not bound by dicta and dogmas, 
but is a progressive science, ready to discard 
the old if it is proved to be fallacious, and 
to adopt the new if it is found to be of value. 
It pays a man to write a paper for a society 
because he has to study and familiarize 
himself with the subject, and thus becomes 
a better doctor. It pays a man to read a 
paper because it gives him a legitimate 
opportunity to show his capacity and expe- 
rience, thus increasing his reputation, or of 
presenting new and original views of the 
treatment of disease, thus adding to the 
knowledge of the profession. It pays a 
man to listen to the papers of others because 
in no other way can he, in the same length 
of time, get so much knowledge with so 
little labor. The discussions which follow 
these papers are especially profitable. In 
them is an impressive personal element 
which is totally lost in the stenographic re- 
port published in the transactions. 

In addition to the educational and pro- 
fessional advantages alluded to, there are 
the equally important social and personal 
benefits to be derived by attending medical 
meetings. The occasion is a. holiday, a 
recreation, a vacation; it breaks the monot- 
ony of life and enables a man to do better 
work when he returns home. It affords 
opportunity to meet men who are doing the 
same work in different sections of the 
countrv, and results in pleasant and profit- 
able acquaintanceship which often leads to 
permanent friendship. And last but not 
least, it brings together men who live in the 
same community, but who, owing to petty 
jealousies or lack of time for social inter- 
course, see little of each other. Either in 
the session of the society or in the committee 
room, or on the journey to and from the 
place of meeting, they are thrown into inti- 
mate contact, which frequently leads to 
explanation, of differences, to the apprecia- 

1 38 


tion of good qualities, and to the establish- 
ment of the most cordial and friendly rela- 
tions. Dr. Osier summarizes the subject 
with characteristic incisiveness in the follow- 
ing paragraph : "The man who knows it all 
and gets nothing from the medical society, 
reminds one of that little dried-up minature 
of humanity, the prematurely senile infant, 
whose tabetic marasmus has added old age 
to infancy. 'It is a waste of time,' he says, 
and he 'feels better at home,' 'and perhaps 
that is the best place for the man who has 
reached this stage of intellectual stagna- 

We will now take up the real work of the 
Society. Owing to the number of papers on 
the program, it may possibly be necessary 
to hold a three-days session as provided in 
Article IV of the Constitution, instead of 
the two-days session as published by the 
Secretary in accordance with the precedent 
established at previous meeting. This ques- 
tion, however, will be discussed by the 
Kxecutive Committee and brought back 
later for your decision. 

1 wish to remind the fellows of the Associ - 
ation that, according to the By-Laws, all 
motions and resolutions are referred to the 
Executive Committee without debate. Also 
that not more than twenty minutes shall be 
occupied in reading any paper, although it 
may be published in full in the Transac- 
tions; and finally, that in any discussion, 
no member shall speak longer than five 
minutes or more than twice on the same 
subject. These rules will be rigidly enforced, 
and it is earnestly requested that no excep- 
tion be asked in any instance. I will also 
state that while special arrangement will be 
made to allow papers to be read by our in, 
vited guests at a time convenient to them- 
that as far as regular members of the Associ- 
ation are concerned, the program will be 
followed as printed, and if an author is not 
present when his paper is called, he will be 
relegated to the end of the list. 

Retained Placenta -Report of a Case, 
With Remarks. 

By J. N. Upshur, M. I)., Richmond, Va., Rx-Presi- 
deni and Honorary Fellow of the Medical Socie- 
ty of Virginia, of the Richmond Academy of 
Medicine and Surgery, of the Tri-State Medical 
Associan of the Carulinas and Virginia. Honorary 
Fellow of the Medical Society of West Virginia, 

I 'sually the experiences reported are 
those in which success has atteded our ef- 
forts for the relief of pain or the saving of 
life. In the following remarks, 1 desire to 
call attention to a case in which in my own 
experience the conditions were extremely 
fare, and the termination of the case un- 

Case. — Mrs. R. became my patient in 

February '06. I found her threatening to 
abort at about the tenth week. She gave 
the following history, she had usually en- 
joyed good general health, was then 33 
years old and had been married nine years. 
She had never carried a child beyond the 
tenth week, and had had five abortions pre- 
vious to my being called. She had been 
under the care of my predecessor for eight 
years. The abortion came promptly, the 
uterus was curetted and she was kept under 
observation for sometime. Subsequently 
she conceived, had a pregnancy devoid of 
any note, and was delivered on Dec. 1st, 06, 
of an eight months baby, after a remarka- 
bly easy labor. The baby was very thin 
and frail. The mother's breasts remained 
perfectly flabby and there was never any 
attempt at lactation. The baby was hand- 
fed and progressed finely and at 9 months 
old though small, was plump and robust 
looking. Conception occurred again, I 
think not later than thirty days after the 
first delivery. She had again an uneventful 
pregnancy, and labor was expected accord- 
ing to the best computation I could make, 
on October 22nd, 'o7, my calculation being 
based on the supposition that conception 
had taken place several weeks later than I 
was subsequently led to believe that it did. 
Labor came on September 11th, there was 
nothing unusual about the first stage, in the 
second stage the pains though regular and 
frequent, seemed ineffective and caused 
much complaint of suffering. After reach- 
ing the midplane there was- no progress, and 
forceps were applied. She was very much 
relaxed. The head of the child was very 
soft and bones felt loose in the scalp. Three 
times the instruments slipped although the 
handles were firmly closed. At the fourth 
attempt, the head was delivered without 
the application of any force. The child was 
a boy, larger than the first child, head thick- 
ly covered with hair and finger nails well 
grown, he was moribund, and required ac- 
tive efforts for twenty minutes or a half 
hour to resusitate him. The mother was 
given 3i of fed. ext. of ergot and 1-20 gr. 
strychnia nitrate, and I attempted the de- 
livery of the placenta, which I supposed 
had followed the usual course and was ly- 
ing loose in the uterine canal or vagina. — 
But failing bv the compression method of 
Crede, I made an examination and found 
the placenta adherent, uterus symetrically 
contracted around it and cervical canal 
only patulous enough to admit the 
passage of the chord. After persevering 
effort I succeeded in introducing my fingers 
into the uterine cavity, the placenta was 
attached on the left latero-posterior aspect 
of the uterus rather low down, had a hard, 
cartlagiuous feel, and I was unable even to 



raise the edge of it. The patient passed a 
good night, entirely free from after pains, 
on Sep. 15th. eighteen hours after delivery, 
being fully anaesthetized, the cervix was 
dilated with a steel divulsor and a placen- 
tal curette, a regular curette, and my fing- 
ers, were all used in the effort to detach the 
placenta, but although persisting in the 
effort for an hour, the patient's condition 
was such as to force me to desist from farth- 
er effort, having accomplished only the 
removal of a small portion with the chord 

softened uterus could not resist the impact 
of the head under the expulsive pains, and 
that in this way the rupture occurred. It 
must be remembered that the history of the 
frequent miscarriages during the preceding 
eight years before she carried a child to 
term, had weakened and impaired the integ- 
rity of the uterine muscle nnd predisposed 
it to the development of an unusual condi- 
tion, when conception occurred under the 
condition described in the case above re- 
ported. In my own experience extending 

attached. Her condition for some hours over a great many years (40) this case is a 
was most critical, and it required full doses most unique one. I am aware of theprob- 

of strychnia and adrenalin to sustain heart 
action. In my effort to remove the placenta, 

abilty of adhesion and consequent reten- 
tion as the result of diseased conditions of 

I discovered a rent in the anterior uterine the placenta, oftener syphilitic than other- 

wall at the junction of the body and cervix > 
transverse and about 2)-i hi. in extent, I 
could easilymeasure it my finger in the uter- 
ine cavity could be felt through the abdom- 
inal wall. She had very little temperature, 

wise, and am sure that the impreesion pre- 
vails that retained placenta is not an un- 
common thing, but I am convinced from 
the research which I have made that from 
all causes it is not so common as is believ- 

it ranging from 98.4° to 101.4°, pulse 100 ed. Dr. II. H. Atwater (American Journal 

to 110 and of fair voume. On Sept. 12th, 
6 p. m., Dr. J. Shelton Horsely saw the 
case with me, it being desirable to deter- 
mine if a complete hysterectomy was justi- 
fiable and would give her a chance for her 
life, he agreed with me that her condition 
was such as to make the danger of moving 

of Obstetricks, Vol. XII pg. 297 ) in an an- 
alysis of one thousnnd cases of labor in 
private practice, had only four cases, the 
paceuta having been safely delivered by in- 
troduction of the hand. In the last four 
hundred cases in my own practice, there 
were three cases, the one reported in this 

too great to attempt it, and that if she paper, one due to syphilis, the third I do not 
reached the hospital safely she would prob- 
ably die on the table. On 14th she passed 
two small pieces of placenta, during that 
day and the early half of the 15th, her con- 
dition was so good I felt much encourged 
about her. On the afternoon of the 15th, 
I Jound her with marked symptoms of pro- been anticipated. A very interesting fea- 
found sepsis, pulse thready, respiration ture is the birth of two infants in such a 
sighing, abdomen enormously distended short period of time, 
with gas, on the 16th she was decidedly 

recall the data, in the last there was 
little difficulty in the delivery. Could the 
complication have been foreseen, 1 am sure 
that a prompt hysterectomy would have 
saved life, but I can imagine, no indica- 
tions by which the complication could have 

worse, death occurring about mid day 

Remarks. — Until I had this experience, I 
would not have believed that it was possi- 
ble for me to fail to deliver a placenta, and 
to have done so was a source of much cha- 
grin. The uterus, as is well known, during 
the process of involution succeeding labor, 
undergoes molecular fatty degeneration, con- 
ception taking place before this process is 

completed it is arrested, and the uterus begins iug," or that have from 
the reverse process of evolution in a softened been vaunted as >l specific! 

The Treatment of Epilepsy. 

By J. Allison Hodges, M. D., Richmond, Va., 
Professor Nervous and Mental Diseases, Univer- 
sity College of Medicine, and Physician in Charge 
Hygeia Hospital Richmond, Va. 

In the discussion of this subject, it is my 
purpose to discard the scientific study, or 
even the mention of the numerous remedies 
that have been suggested, and ' 'found want- 
time to time, 
' and been as 

condition unfit for the function which it is quickly relegated to the already overbur- 
called on to perform. So when the time for deuedlist of proposed curative agents which 
the development of the placenta arrives, often have had nothing, even for an experi- 
and its attachment is formed, it becomes mental basis, except the promulgation of a 
fused into the uterine tissue forming tena- new theory, or the propagation of a novel 

cious adhesion which in the above case I 
was unable to overcome. Though the 
patient complained of the pains in the sec- 
ond stage of labor, in force, they were not 
of unusual severity, nor was any force used 
in the delivery of the head with instru- 
ments. It is clear to my mind, that the 

hypothesis by some self-advertised enthu- 

In the course of centuries, the intensely 
interesting fact that no definite cause could 

tRead as leader of debate before the Tri -State 
Medical Society of N.C., S.C., and Va., Charlotte, 
N. C. 



be logically assigned for this disease, has 
led even some of the most earnest investi- 
gators into paths of the wildest speculation 
as to the theoretical bearing of certain rem- 
edies upon some of its manifestations, and 
in this way, there is scarcely a drug in the 
shoos that at one time or another has not 
been regarded and recommended as infal- 
lible in the cure of disease. Unfortunately, 
all these claims have been proved to be 
false, and we are to-day as helpless to cure 
epilepsy with one drug, as was our profes- 
sion five centuries ago. 

Within the past few years, however, there 
have been marked advances made in the 
treatment of this disease, and my purpose 
to-day is not to rehearse the classical thera- 
py of the past, but, rather, to discuss only 
those measures which, in my practise, have 
seemed to yield such results as would right- 
fully entitle them to careful professional 

In my personal experience, I have found 
epilepsy to be one of the most difficult of 
the diseases of the nervous system to treat, 
and while I believe that the passing years 
have added to the stock of my general 
knowledge on this subject, yet it is not pos- 
sible for me to name any one remedy, or 
remedies that I can rely upon as either cur- 
ative, or in any sense, specific in therapeu- 
tic effects. 

The continued study of this interesting 
and humanilarian subject has, however, 
dispelled not a few vague and illusive theo- 
ries of mine, and has taught me many prac- 
tical lessons. 

It has taught me in a general way regard- 
ing the treatment of this disease: (l) 
That the idea that nothing can be done by 
us for the epileptic has for too long 
prevailed, and that it is high time these 
poor unfortunates, as well as the laity, be in- 
formed that, certainly, symptomatic epilep- 
sy can be, and is often cured, but the cure 
of idiopastric epilepsy is rare, I personally 
having never cured a case; (2) that the 
want of interest, and frequently the care- 
lessness manisested by physicians them- 
selves in this class of patients, often dis- 
crediting their own ability by dismissing 
them with a prescription as useless, as their 
prognosis is hopeless, is unwarranted and 
unworthy of their achievements in the bat- 
tle against other diseases, which in the 
near past have been apparently as hopeless 
as this, notably consumption, bright's dis- 
ease and many forms of paralysis, 
but which under the increased interest, zeal 
and research of the profession have now 
come to be diseases not so much to be dread- 
ed as to be combated; (3) that neither 
medicine nor surgery per se will efficiently 
and permanently cure this disease, and that 

we must have the greatest respect for the 
smallest things, and this respect must nev- 
er relax; (4) that the treatment of a single 
organ in the body for a cure of a disease as 
violent and as destructive as epilepsy in its 
essential type, is as unreasouble as it is un- 
scientific, for while an irritant cause may 
be removed, yet the habit may, and does 
generally remain, and neither procedure 
alone will cure the disease; (5) that the 
day of routine bromide dosing is happily 
passing, for the disasters from the remedy, 
carelessly administered, have been found to 
be as great, or greater than the ravages of 
the disease itself ; (6) that there are "epi- 
lepsis and epilepsis, " the forms, varieties 
and subdivisions being many, and that to 
properly treat epilepsy, its peculiar type and 
cause must first be carefully and systemat- 
ically studied; and, lastly, that treatment 
begun early and long and faithfully main- 
tained, consisting of measures that are pro- 
phylactic, hygienic, medicinal and surgical, 
if need be, hold out the best and only hope 
for permanent relief from .this terrible mal- 
ady, which makes of its victims, civil and 
social outcasts, and consequently calls for > 
the most strenuous efforts on the part of the 
earnest and conscientious physician. 

In the study of the individual cases that 
have come under my care for treatment, I 
have striven always to bear in mind that epi- 
lepsy is often a symptom, and that the treat- 
ment of each separate case was to be depen- 
dent upon the solution of the important 
question of diagnosis. I usually ask my- 
self, is the case in hand symptomatic of a 
lesion of the brain, of the spinal cord, or 
of the peripheral nerves; is it an accompan- 
iment of the cerebral palsies of childhood, 
or does it bear a distinct relationship to 
heart disease, nephritis, mulnutritiou, or 
marked disturbances of the gastrointesti- 
nal tract, the sexual organs, or the eyes ? 

Again I find no two cases alike, almost 
every one having its own peculiarties, and 
it is often a most difficult task to decide 
whether the attacks constitute alone the 
disease, or whether they are merely a symp- 
tom of a primarily affection which is at- 
tended with still other manifestations, and 
the determination of this point also influ- 
ences the proposed line of treatment. 

These facts settled and organic lesions 
excluded, the matter of treatment is deter- 
mined, and briefly speaking, this resolves 
itself into prophylactic, constitutional and 
specific measures, according as the disease 
appears to be symptomatic, or genuine epi- 

Prophylactic Treatment : — 

The first and essential rule of treatment, 
which is applicable to all clases of cases, 
is that, remembering the epiletic age is from 



five to fifteen years, that when there has 
been a convulsion, and especially a recur- 
rence of a fit between the ages of five and 
ten, the case should excite apprehension 
and should call for the most diligent treat- 
ment, and this treatment should be kept up 
constantly for at least three years after all 
attacks have ceased. I believe this to be a 
most important point which is often over- 
looked by the practitioner, and especially 
by the family physician. 

Constitutional Treatment : — 

This method of treatment seeks to use 
those agencies which tend to decrease neu- 
ralgia proliferation and increase vasomo- 
tor tonicity of the system. Arsenic, mer- 
cury and iron, the albuminate and pep- 
tonate, fulfill the former indications, 
and the use of water, .by means of cold 
sponge baths, wetpacks. showers, jet douches 
etc. according to the opportunities of the 
patient, fulfill the latter. 

Daily work in the open air, or at a trade 
that is congenial, has also been found to 
be mentally, as well as physically hygienic, 
and quiets and steadies the nervous system, 
sometimes absolutely checking the disease. 

The next most important factor in the 
line of constitutional treatment is the elim- 
ination of the waste products of the system, 
and the consequent prevention of autotox- 
emic conditions resulting from intestinal de- 

This is best obtained by an absolutely asep- 
tic and non-irritating dietary with dimuni- 
'tiou of salt, such as milk, meats in modera- 
tion and eaten slowly, and bread. Proper 
attention to the frequent constipation and 
dyspepsia is of course, necessary, and must 
be rigidly observed and enforced. 

Hydropathic methods, by means of Ba- 
ruch baths, if obtainable, hot packs, the 
free injection of large quanties of water 
between meals, etc., are most important 
adjuvants to this end. Sinusoidal electric- 
tricity, if available, is also to be recom- 
mended, as an efficient agent in assisting 
metabolism, and correcting specific syste- 
mic poisoning. 

In my opinion, our profession has not 
laid sufficient stress upon the toxic condi- 
tion which exists in so many of our patients 
suffering from this disease, and which 
arises from deep-seated errors in the funda- 
mental principles of nutrition. If we would 
apply to many of these cases, the maxim of 
"clean out, clean up, and keep clean," 
which has for the most part, and I believe 
very illogically, been relegated almost en- 
tirely to the realm of surgery, and insist, 
furthermore, upon our patients learning 
the value of work, which would bring 
about aself-forgetfulness and satisfaction, 

if not pride in life, our results would be far 
more brilliant, and much more successful. 

In fact, I have seen more than one con- 
firmed case entirely cured by these means 
alone. The methods indicated imply per- 
severance, skill and tact upon the part of 
the physician, but is not the result worth 

The eliminative method, of course, also 
presupposes the removal of all external 
irritants as well, but I believe the import- 
ance of reflex irritations has been much 
overestimated, except those arising from 
the gastro-intestinal tract, as mentioned 
above, the sexual organs, and the eyes. 

It is a useless task, it appears to me, to 
argue that the treatment of a single organ 
will cure a destructive disease like Epileysy, 
which in its very nature must affect the 
whole body, and consequently, clipping eye 
muscles, for example, would not in my 
opinion be expected to cure anything more 
than a pseudo-epilepsy. 

Generally speaking, not only must the 
cause be removed, but there must be a cor- 
rection of the established habit. The phy- 
sician here has a double problem to solve, 
and should not be satisfied with the accom- 
plishment of but the half of his task. 

Alterative remediessuch as arsenic, saj- 
odin, the iodides etc., are indicated as "hab- 
it breaking' ' drugs, and in conjunction with 
theusual constitutional measures detailed, 
are of great assistance for this purpose. 

Specific Treatment: — 

Without enumerating the drugs which 
hold a reputation as anti-epileptics, I will 
say that the most valuable of the so-called 
specific drugs are the bromides and bella- 
donna. All of the bromides act alike in 
this disease, and if one one does not dimin- 
ish the attacks in number and severity, an- 
other will not. They all act alike, also, on 
the patient's system, all being depressive, 
if too habitually used, to the higher nerve 
centres, and if exhibited for a long period, 
it often requires a trained observer to dis- 
tinguish between the symptoms due to the 
drug, and the symptoms from the disease 
itself. While I believe that the professioa 
is under a debt of lasting obligatien to Lo- 
cock, who in 1853, introduced the new era 
in the treatment of this disease, by suggest- 
ing the bromide of potassum for the con- 
trol of the convulsive manifestations, yet 
The abuses of the bromides in the thera- 
py of epilepsy are, in my judgment, often 
graver than the advantages of the remedy. 

I believe further, that the bromides per se 
are powerless to cure epilepsy, for rationally, 
a reconstructive, and not a destructive med- 
icine is indicated. 

That they have the power to suppress the 
convulsive phenomena, and occasionally 



for long periods, no one will deny, but I 
contend that suppression of the convulsions 
alone is not the cure of the disease, and 
that it is irrational and illogical to give such 
a remedy without regard to the cause, or the 
type of the disease which is being treated. 

Its careless administration and whole- 
sale employment have, I repeat, produced 
drug symptoms as dangerous, as debilitat- 
ing, and as destructive as the disease irself. 

Us guarded use, however, I believe 
lieve to be necessary in most cases, but I 
would insist upon as small doses as possi- 
ble to control the convulsive seizures, and 
give this dese always largely diluted with 
water, preferably aerated, and while so do- 
ing, never neglect for one day, or one hour, 
the skin and the bowels of the patient. 

It is not necessary to produce "bromism" 
to get beneficial results; it is better not to 
do so. 

It is well to remember too, that anemic, 
nervous epileptics who lead a sedentary 
life are improper subjects for the bromide 
treatment, the Ferrocyanide of Iron being 
a more suitable remedy. 

The bromides lessens the fits in about 80 
per ct. of cases, and do no good or do actual 
harm, as regards frequency of attacks, in 
from five to ten per cent, of cases. The 
The best bromide salts, in my experience, 
are those of Strontium and Sodium, as these 
are usually best and longest borne by the 
stomach, though occasioaally a change, or 
combination appears to be advantageous. 

One of the best adjuvants to the bro- 
mides, as Seguin pointed out, is chloral hy- 
drate in very small dosage, or the eyes and 
stomach of the patient may become affected. 

Children bear proportionately large doses 
of the bromides, and if an adjuvant is re- 
quired to control the fits, oxide of zinc is 
useful in these cases. 

In some of the special forms of epilepsy, 
ceriain other remedies have special value, 
such, for instance, as urethane, or the ac- 
tual cautery in the Jacksoniau type,sodium 
salicylate in the lithaemic form, etc. 

As a rule, it is best not to use counter- 
irritants in the usual types, nor is it well to 
use suchl remedies as uitriate of amyl to 
prevent impending attacks. In status 
epilepticus, morphine is dangerous, vene- 
section and large chloral enemata yielding 
the best results. 

In the vain hope of effecting a cure in 
many cases of long standing and which 
w T ere uncontrollable by bromides, regula- 
tion of diet and proper mode of life, phy- 
sicians of a generation ago were prone to 
suggest "surgery and see what would hap- 
pen." This spirit of expectancy, and, in 
a sense, of desperation has not yielded sat- 
issactory results, and it is an interesting in- 

dex of how completely the standpotnt of 
generations ago has been changed, when, 
now, many efficient and fearless operators 
recommend conservatism in the surgical 
treatment, of even traumatic epillepsy. 
This tendency to differentiation of the cases 
is a wholesome sign of thoughtful conserv- 
atism, and will save us in the future from 
the necessity of apologizing for reckless 

The old operations of ligation of the 
carotids and of the vertebral arteries have 
long since been discontinued. 

With our present knowledge of cerebral 
localization, cases caused by removable 
intracranial lesions should be operated up- 
on, if the localization of the latter can be 
definitely made, and the convulsions con- 
stantly occur in the same group of muscles 
and extend in a characteristic manner, or 
if transient hemipareses occur, but the'na- 
ture and location of the lesion should 
always be determined, as well as the acces- 
sibility of the area, before surgical inter- 
vention is advised. 

Whenever the disease can be distinctly 
and directly traced to a blow on the head, 
the question of trephining should be con- 
sidered, and with such a history of fracture, 
or present evidence of fracture, or even ev- 
idence of severe head injury with ^directly 
resultant symptoms of the disease, trephin- 
ing is justifible. 

It is exceedingly questionable, however, 
whether the epileptic habit can be cured by 
an operation of any kind. On the whole, 
and briefly stated, surgery can do but little 
for acquired, and nothing for idiopathic 

The Colony Plan, representing, as it 
does, the best features, and in the best man- 
ner, of the points in the line of treat- 
ment already detailed, has been proved to 
be the most eminently scientific, systematic 
and successful method in the treatment of 
this disease. 

Confusion and Errors in the Diagnosis 
of Rheumatism.* 

By Lewis M. Gaines, M. D., Atlanta, Ga , formerly 
Professor of Physiology Medical Department 
Wake Forest College, Wake Forest, N. C. 

It is doubtful whether one man out of ten, 
who has reached middle life, would when 
interrogated, reply that he had never had 
what is called rheumatism. And yet it is 
likewise doubtful whether more than one of 
the ten ever had what should be called 
rheumatism. Thus is there a belief — wide- 
spread among the laity but by no means 
confined to it — that most deep seated pains 

"Read before the Tri-State Medical Association 
meeting at Charlotte February ]8, 19 u8. 


in the trunk and limbs, not admitting- of ing the micrococcus rheumaticus is being 
any very direct explanation must perforce tentatively accepted by many authorities 
be a mysterious manifestation of that elus- though questioned by others. The attempt 
ive malady. Perhaps some day not so far to prove the organism an attenuated form 
distant, some one will be found who, crav- of the streptococcus has probably failed 
ing Dr. Oliver Wendell Holmes' pardon, and we may look forward to the possible 
will write a parody entitled "Rheumatism establishment of the micrococcus rheumati- 
and Kindred Delusions." cus as the cause of the disease. A recent 

That confusion and errors attend the P a P er of Dunn, of Boston, on the clinical 
diagnosis of so-called rheumatic affections manifestation of the disease in children 
all must admit. I would make a distinction tends to support the view that it is an acute 
between coniusion and error. By confusion infectious disease. ^ 

I mean a frequently unavoidable indecision I n case of the term chronic rheumatism" 
as to what to call a disease, correctly diag- the problem is more complex, because such 
nosed, or a lack of uniformity in designat- a large group of affections have been placed 
ing the same morbid condition, often due to under this head. Old terms die hard. Pet 
the retention of misleading synonyms. By phrases long used m connection with cer- 
error I mean a mistaken diagnosis. tain diseased conditions have their usage 

„ sanctioned, oftentimes, by habit rather than 

Confusion in Diagnosis. by justified knowledge. ' I trust I do not 

The confusion which exists in designating offend some or weary others by thus referr- 
so-called rheumatic diseases results largely ing to the so-called "uric acid diathesis," 
from the present unsatisfactory nomencla- or "lithaemic condition." This term was 
ture. As Rotch points out, while patho- introduced into medicine many years ago 
logical classification has been steadily keep- by the celebrated Murchisou to designate 
ing up with pathological research, and certain functional disturbances of the liver 
terms in physical diagnosis revised and connected, as he supposed, with the elirni- 
improved, our nomenclature of diseases has nation of uric acid. "Behold what a great 
not kept pace with our knowledge of them, matter a little fire kindleth." Osier tells of 
The term, rheumatism, is still indiscrimi- on e writer who enumerated not fewer than 
nately applied by many to all acute or thirty-nine separate morbid conditions as- 
chronic pains referred to joints and their sociated with lithaemia! Among these 
neighborhood thus includingtendons.fibrous thirty-nine we may safely conclude rheum- 
tissue and muscles. In fact, most unac- atism occupied a prominent place, 
countable pains in the limbs and not a few The basis of all knowledge concerning 
in the back are labelled rheumatism. In morbid changes due to uric acid must neces- 
many cases, certainly, this is due to our sa rily rest upon an adequate conception of 
present insufficient knowledge concerning the normal metabolism of this substance in 
the etiology of these conditions. Slowly the body. And yet there still exist many 
but surely we are advancing in our knowl- gaps in the chain which is being forged to 
edge in this direction. Many cases formerly connect the events of uric acid metabolism, 
designated rheumatism have been relegated We are fairly sure of its source, we know 
to their proper place in the nomenclature many of the organs in which it is elaborated; 
so that in modern literature to a large extent but these are only isolated events, and as 
the term is limited to joint affections. A poinLed out by Mendel in an excellent 
step further has been taken. Since many critical review of the most recent work done 
of these conditions are infectious in their ou uric acid origin, examination of the 
nature they have been properly designated urine alone means nothing, for a diminution 
"arthritis," which term should always be may indicate diminished production, or in- 
exclusively whenever one can be reason- creased destruction as well as decreased 
ably sure of the infecting organism. For elimination. 

example, gonorrhoeal arthritis is preferable Furthermore, assertions of its pathological 
to gonorrhoeal rheumatism. significance are almost entirely hypothetical. 

Further than this, we should discard the After an exhaustive discussion of the entire 
term "acute rheumatism," which means work on uric acid, which had been done up 
almost anything to the laity, and substitute to 1905, Barker concludes that gout is the 
the term ' 'rheumatic fever. ' ' The evidence only disease in which there is yet any strong 
is multiplying that this disease is compar- probability that disturbances of uric acid 
able to other acute infectious fevers such as metabolism are directly and mainly respon- 
typhoid fever and cerebro-spinal fever, that sible for the clinical symptoms. And in his 
it is a general infection with local manifes- closing sentence he even doubts^ its signifi- 
tations in the synovial and other serous cance in gout when he says, ' After all it 
membranes. The large amount of critical may turn out that disturbances of metabol- 
work which has recently been done in isolat- ism of a nature uuguessed as yet by us may 



be more iinportanl in the pathogenesis of 
gout than the disturbances of uric acid 
metabolism." Since Barker wrote these 
words nothing has l>een done to disprove 
the assertion. That uric acid is of all the 
purin bodies the least toxic when injected 
into animals, who show no general symp- 
toms after large doses, is significant. The 
practitioner who believes his patient suffers 
from "uric acid diathesis" naturally directs 
all his energies against uric acid. But here 
is experimental evidence at hand to show 
that he can have no means of knowing any- 
thing about the amount of production, 
destruction or elimination, and granting he 
did, he could not then show its toxicity to 
be sufficient to account for the symptoms. 
Surely all that can be asserted is that me- 
tabolism is disordered. 

Although our knowledge is still very in- 
complete concerning the origin of the so- 
called rheumatic pains due to the so-called 
"uric acid diathesis," light is being shed 
on the subject by the careful study now 
being given to auto-intoxication. Very 
suggestive is a recent paper of Forscheimer, 
who reports a series of 77 cases, diagnosed 
on excellent clinical and therapeutic evi- 
dence, chronic intestinal auto-intoxication. 
He shows that of his 77 cases, 50 showed 
symptoms or diseased conditions in joints 
or muscles. Of these 50 cases, 19 had gouty 
joints, _'4 muscular rheumatism, 13 rheu- 
matic muscular pains which were transitory. 
A large percentage had indicanuria which 
is undoubted evidence of intestinal putre- 
faction. Shall we not, then, at least con- 
sider a revision of our views regarding the 
large group of rheumatic pains we have 
been referring to uric acid? All modern 
work is surely pointing to the belief that 
uric acid is only an expression of disordered 
metabolism, and should no longer be regard- 
ed as a causative factor. 

If we will consent to call muscular rheu- 
matism, myalgia, believing that it is inflam- 
matory in its nature, we shall have left as 
a common affection at least, only that 
chronic condition of stiff joints in elderly 
people, which may wiih propriety be called 
rheumatism for want of abetterterm. Per- 
haps later we may discard even this, and 
the much abused long suffering scapegoat 
will be laid at rest. 

Errors in Diagnosis. 
If the present confusion referred to can 
be avoided by a proper relegation of terms, 
errors in diagnosis will be less frequent. I 
desire to call attention, however, to errors 
that are not infrequent in three groups of 

First, the mistake of confusing septic 
pyaemia and rheumatic fever'. The mode 

of onset is frequently quite similar, though 
a definite chill is common in sepsis and rare 
in rheumatic fever. There is still fresh in 
my mind a case in point, wdiich I recently 
reported in the Journal of the American 
Medical Association. A lad of thirteen 
received a wound while playing basket- 
ball, and suddenly, three weeks later, had 
a chill, which was followed immediately by 
the development of acute arthritis. The 
physician diagnosed rheumatic fever. When 
I saw the boy a week later, he had a severe 
poly-arthritis, fever, and endocarditis — quite 
like rheumatic fever. But he had also a 
diffuse swelling of the limb whereon the 
wound was, and a large amount of exuding 
serum, just under the cuticle. A smear 
showed streptococci, which were also abun- 
dant in the urine, even forming renal casts. 
The conditions under which a case of this 
character occurs, together with discriminat- 
ing tests, should clear up the diagnosis. 

Second, failure to recognize certain types 
of rheumatic fever in children. Dunn, of 
Boston, has contributed a valuable paper 
on this point as the result of a critical study 
of 300 cases of rheumatic fever in children. 
He finds the disease often presents peculi- 
arities in early life, the most striking of 
which are the comparative mildness of the 
articular manifestations associated with the 
relative frequency of cardiac involvement, 
which is often severe, and may be the first 
sign of the disease. So impressed is he 
with these results that he believes any acute 
infectious disease occurring in a child, in 
which no other evidence of localization 
occurs except in the endocardium, peri- 
cardium, or joints is probably rheumatic 

Here then is the clinical evidence by 
which it seems probable that rheumatic 
fever is an acute infectious disease, and 
that cardiac involvement is not necessarily 
a complication, but in many cases a primary 
manifestation. To guard against error, then, 
the evidence of the heart alone must be as 
valuable as that of the joints alone. Need- 
less to say, here is another reason for always 
examining the heart with exceeding care. 
The application to prognosis and treatment 
is evident. 

Third, recognition of the true nature of a 
group of cases heretofore explained by that 
mystic phrase "uric acid diathesis." Prom 
the work and conclusions of Porscheimer, 
and others, we must believe that many such 
cases are suffering from the effect of toxines 
derived from the putrefying contents of the 
intestine. Certainly treatment directed 
against this condition is frequently attended 
by the happiest results. At the same time 
Forscheimer warns against ascribing too 
much importance to intestinal auto-intoxi- 



cation in every case. The main points in 
the diagnosis are the presence of Riggs' 
Disease, functional changes in the colon, 
demonstrable retention of feces, indicanuria, 
headaches, cardio-vascular symptoms, joint 
and muscular symptoms. Here certainly 
is a more tangible cause to which rheumatic 
pains may be ascribed than to uric acid, 
for we know the products of albuminous 
putrefaction are toxic. Should we not ac- 
cept this view as a working hypothesis, if 
it serves to direct successful therapeutic 

As a remedy for errors, allow me in con- 
clusion to make a plea, first for a better 
understanding of pathology — a pathology 
which is not thought of as unpractical or 
visionary or barren of application, but as 
stimulating and helpful and borne con- 
stantly in mind to illuminate the clinical 

In the South there is a sad lack of oppor- 
tunity — perhaps it is inclination — to study 
pathology first hand in the autopsy room. 
Some weeks ago when in one of the largest 
and most progressive cities in the South, a 
medical center, where six hundred medical 
students flock annually, a prominent phy- 
sician told me it was the rarest thing for an 
autopsy to be performed in that city, and 
that he did not believe a microscopic exami- 
nation of five tumors a year were made 
there. Surely this is a distressing condition 
if we are to believe that pathology is funda- 

Secondly, I would make a plea for a more 
painstaking careful examination of patients. 
It is a threadbare but truthful charge that 
the majority of physical examinations are 
superficial. A urethral examination may 
tell an interesting story about the cause of 
puzzling joint symptoms; a faint heart mur- 
mur may shed light on the reason why a 
child is so anaemic and has persistent 
"growing pains" about the joints. In this 
connection, I shall never forget the case of 
a long lean negro youth who came into Dr. 
Osier's clinic during my student days. He 
complained of pain and stiffness in his neck 
and general weakness, associated with diffi- 
culty in walking, and shooting pains in his 
limbs. He served as the basis for a most 
excellent discussion of multiple neuritis. 
Some days later the boy appeared again 
looking more distressed than before. p It 
occurred to Dr. Osier to not only look into 
his mouth but to feel in it. A large fluctu- 
ating retropharyngeal tubercular abscess 
very readily gave the diagnosis, and Dr. 
Osier, with his characteristic candor, said 
that he had himself learned another lesson. 
From what we are led to suspect concern- 
ing the etiology of various so-called rheu- 
matic affections we may infer that not alone 

the tongue but the mouth and throat as well 
are the root of all evil. As examples con- 
sider the association of rheumatic fever and 
tonsillitis, and that of Riggs' Disease and 
chronic intestinal auto-intoxication, to say 
nothing of the epigrammatic assertion that 
most men dig their graves with their teeth. 
When reasonable doubt exists every 
method of diagnosis at command should be 
employed. The microscope may show urate 
crystals from suspected tophi characteristic 
of gout, or, as in my case, streptococci in 
the urine. A radiograph, properly inter- 
preted, may give valuable information as 
to the true nature of certain chronic joint 
symptoms, chemical examination of the 
urine for indican may establish the diag- 
nosis of a high grade of intestinal putrefac- 
tion, bacteriological examination of the 
blood may demonstrate the presence of 
virulent micro-organisms which may be 
identified and possibly combatted. 

1 . The diagnosis of rheumatism is attend- 
ed with much confusion and error. 

2. This confusion is referable in part to 
lack of advance iu revising the nomencla- 
ture, in part to the lack of knowledge con- 
cerning the etiology of many rheumatic 
conditions. The first factor is remediable, 
the second is slowlv disappearing. 

3. The term "uric acid diathesis" should 
be discarded, and uric acid as a cause of 
disease questioned. 

4. Among errors in diagnosis are the con- 
fusion of septic pyaemia with rheumatic 
fever, the non-recognition of certain types 
of rheumatic fever in children, and failure 
to distinguish chronic intestinal auto-intoxi- 

5. A greater interest in, and better under- 
standing of pathology, and more care in 
the examination of patients would eliminate 
many errors. 

74S Juniper Street. 

Delirium Tremans.* 

By Robt. S. Carroll, Asheville, N. C. 

The aCute alcoholic insanities may be 
divided into mania-a potu, dipsomania and 
delirium tremens. 

Mania-a-potu. Mania-a-potu is an acute 
insanity, the direct result of alcoholic ex- 
cesses in predisposed individuals, following 
a short period of dissipation. Mania-a-potu 
rarely attacks regular drinkers. It often ap- 
pears without warning, the victim being 
seized with a homicidal or destructive fit, 
fully as unexpected as the seizure of an epi- 
leptic, and like the epiletic victim may be 

JRead before the Tri-State Medical Association 
meeting at Charlotte Feb. iS, 190S. 

1 1(> 


completely unconscious of his actions or 
surroundings. Many of the tragedies oc- 
curing during drunken furry are those in- 
sane acts of man made mad by alcohol. 

The distinction being mania-a-potu and 
delirium tremens is a decided one, the illu- 
sions, hallucinations, tremor and terror of 
the delirient are entirely wanting in the 
insane rage of the acute alcholic maniac. 
Practically all cases of mania-a-potu occur 
after short drinking bouts, and in suscep- 
tible individuals always follows the use of 
alcohol even in moderate quantities. The 
pathology of this condition is that of an 
acute cerebral congestion resulting from the 
irritating effects of alcohol. Such being 
the case, the treatment is clearly indicated. 
Proper restraint, affording protection to the 
patient and family, the immediate with- 
drawal of alcohol, active catharis and light 
nourishing diet fulfill the requirements. 

Dipsomania. Dipsomania is mentioned 
only for differentiation. This is a periodic, 
uncontrolable craving for the anesthetic 
effects of alcohol. Many dipsomaniacs ab- 
hor the smell or taste of any form of liquor. 
Practically all dipsomaniacs are the desceu- 
dents of alcohol using parents, and are to 
a certain extent defective. The treatment 
of dipsomania is one of the most difficult 
tasks which taxes the skill and patience of 
the neurologist, it being, in fact, the treat- 
ment of the neuropathic basis. A moder- 
ate percentage of those, unfortunates are 

Delerium Tremens. 

Definition: Delerium tremens is that 
form of acute insanity following a prolong- 
ed use of alcohol characterized by deliri- 
um, with hallucinations, illusions, tremor 
and usually marked fear or actual terror. 

Etiology: This disorder rarely follows a 
short spree, but in the great majority of 
cases is the culmination of a long, hard 
period of drinking. Some regular users of 
alcohol may slowly increase the quantity 
for ten, fifteen or even twenty years, before 
the attack of delirium tremens occurs. 
Therelare several misconceptions connected 
with delirium tremens, one of the most 
common being that the attack follows the 
sudden withdrawal of alcohol. This is far 
from being the case. The real cause of 
delirium tremens is defective kidney action, 
preventing the elimination of the products 
of the metobolism of alcohol, which pro- 
ducts, act as toxic agents and produce symp- 
toms markedly different from the effects of 
alcohol. Not only is the withdrawal of 
alcohol not the cause of delerium, but care- 
ful observation will prove that in the major- 
ity of cases, after the system becomes satu- 
rated with these products allowed to accu- 

mulate therein by imperfectkidney activity, 
the patient will voluntarily discontinue 
drinking, and in many cases refuse liquor 
when offered him. I do not remember hav- 
ing seen this point recorded, yet this sud- 
den disinclination for liquor has been pres- 
ent in the majority of cases which I have 
seen during the first stage. In my experi- 
ence albuminuria and casts are usually 
present. Leimann reports albuminuria in 
nearly eighty percent, of all cases, while 
Hertz finds impairment of kidney function 
in all well developed cases. With this con- 
ception of the etiology of this serious dis- 
order the treatment will, I believe undergo 
marked modifications. Let us remember 
that the purity of the alcohol used plays 
secondary part in the causation of the un- 
fortunate condition, for attacks of delerium 
tremens may follow the ingestion of the 
highest grade of spirits. 

Traumetism, particularly accidental in- 
jury, may cause active delirium through 
neurotic shock even in the absence of alco- 
hol, hence it becomes an active determin- 
ing factor in the production of delirium 
tremens in regular drinkers and markedly 
so when the injury occurs during a spree. 

Pathology: Delirium tremens, then, is 
due to the damaging influences of toxic 
material produced within the system 
by the dissimilation of alcohol, which un- 
der favorable conditions is eliminated by 
the kidneys. This poison is a potent cere- 
bral and cardiac irritant, producing 
intense mental activity and rapid, weak 
heart, a poison may determine a fatal ex- 

Symptoms : The symptoms arrange them- 
selves into two groups, those of the prede- 
lirious or prodromal stage and the stage of 
active delerium. In the prodromal stage, 
which may last several days, restlessness, 
apprehension, irritability, sleeplesness, and 
often nausea and vomiting are present. 
During this period the patient fails to de- 
rive the usual soothing and quieting effects 
from his imbibitions. Something is wrong, 
forgetfulness and spurious cheer are no long- 
er in his cups, Recognition of this stage is 
thoroughlly important in the treatment, 
for during this period, intelligent control of 
the patient may prevent the serious stage 
of active delirium. 

The onset of the delirious stage is mark- 
ed by evidences of false perceptions and 
conceptions, illusions of sight being the 
most frequent. The picture becomes a 
living face, the pillow an animal, the folds 
of bedding serpents crawling toward and 
over him, and so on, an endless variety of 
miserable, fearful and oft times horrifying 
self deceptions. Illusions and hallucina- 
sions of all the senses may occur. A char- 



acteristic, peculiar to delirium tremens is that 
these false impressions are almost always 
distressing in nature, and as a result, the pa- 
tient is frightened, often terrified, some time 
the frenzy of fear is such as to lead to sui- 
cide. The memory of these horrible con- 
cepts may be lost after recovery, but in 
many patients the impressions made are 

In uncomplicated cases the temperatute 
rarely exceeds 100° when higher some com- 
plication is usually present. The pulse 
however, is out of prepartiou to the temper- 
ature and is always rapid and frequently 
weak. Acute cardiac dilatation not infre- 
quently occurs during on attack of delirium 

Diagnosis : The diagnosis in a developed 
case presents no difficulty. Recognition of 
the impending danger during the prolonged 
stage, is less frequent. 

It is well to anticipate trouble in the case 
of a hard drinker, when he fails to obtain 
sleep from additional quantities of alcohol, 
or when, with sleeplessness a sudden dis- 
taste for his usual stimulent appears. 

Prognosis: We must consider an attack 
of delirium tremens a serious illness. Con- 
servative authoraties place the death rate 
in simple cases at three to four percent, in 
complicated cases at from ten to fifteen 
percent. Ordinarily, after an active deliri- 
um of from two to five days the patient 
passes from delirum into sleep, the so-call- 
ed ''critical" sleep, which may last from 
12 to 30 hours, and from which he wakens 
rational, and desiring food. Convalescence 
is then established. 

All patients suffering from delirium tre- 
mens are abnormally susceptible to infec- 
tions, pneumonia being a particularly fre- 
quent and fatal complication. Terror, born 
of the frightful concepts not infrequently 
leads to suicide. Accidental death result- 
ing from the patient's efforts to escape is 
another fairly frequent termination. Many 
of these delirious patients would readily 
leap through a fifth story window as to pass 
out of the door. Exhaustion and collapse 
preceed death in a smaller percentage of 

Unfavorable symptoms are auditory hal- 
lucinations, temperature above 102° con- 
vulsions, stupor and coma. If the defec- 
tive kidney elimination should be the result 
of an active nephritis, the dangfer of ure- 
mia, with coma and a fatal termination is 
much increased. 

Treatment : I have recently taken occa- 
sion to look up carefully the treatment 
given in a number of our standard text 
books on general practice and mental dis- 
eases, and I have been appalled by the num- 
ber of these authorities, who in the face of 

our present knowledge of the pathology of 
delirium tremens, still advise the use of 
chloral, morphine, synthenic hypnotics, the 
bromides, alcohol, hyosin, and potent com- 
pounds of these drugs in the treatment of 
this grave intoxication. I mention such 
treatment but to condemn it. My attention 
was called to this subject by the knowledge 
of the following case: — a professional gen- 
tleman of less than forty, entered an excel- 
lent hospital to be sobered from a spree 
which! had lasted something over two 
weeks. A man physically and mentally 
robust, but who had been a periodic 
drinker since maturity. He rapidly devel- 
oped delirium, was noisy and violent. On 
the sixth day he was in come and died on 
the seventh day. The third day of delirium, 
with a pulse running from 140 to 160, he 
received 15 grains of chloral 190 grains of 
bromide of potash, one and one half grains 
of and one half grains of sulphate of mor- 
phine hypodermically. Within five days, 
he received a total of 580 grains of 
potash, 60 grains of chloral, 140 grains of 
vernoal, one and one half grains strych- 
nine, one sixth of a grain of digitalis, three 
grains of sulphate of morphine, besides 
paraldehyde and adrenalin. This man was 
treated according to the advice of many of 
our good text books, he was treated by 
good men; consciensious and earnest, and 
had the benefit of counsel. Doses were 
repeated in the vain effort to produce sleep 
in the face of a fiere cerebral excitement, 
when sleep did come it was come. We know 
this case is but an example of the treatment 
frequently received by these troublesome 
ucfortunates. The question occurs, what 
would be the result of administering this 
quantity of medication to any strongman, 
unweakened by previous intoxication? 
Might not the supervention of coma and 
the endless sleep be reasonably expected ? 
This paper is written to emphasize the real 
cause of delirium tremens and to protest 
against the use of additional powerful, 
vital depressors when the patient is already 
staggering under a burden of damaging 
toxic material. 

Prodomal stage: The rational treatment 
of delirium tremens is disticntly different as 
applied to the prodromic and delirious sta- 
ges. When, as a result of the irritating in- 
fluences of prolonged or excessive use of 
alcohol, the kidney epithelium becomes in- 
jured and the regular elimination of the 
products ot alcohol metabolis mare retained 
in the circulation, the central nervous sys- 
tem rapidly feels the effects of this toxic 
material and manifests its presence by ap- 
prehension, restlessness and insomnia. 
The first rational indication therefore, is to 
stop the alcohol and substitute for its stim- 



ulating effects such drugs as do not leave 
the damaging residium of alcohol. It is 
during this stage that marked relief may be 
obtaiued bo the use of an active sweat bath, 
and it is during this stage only that the use 
of hypnotic ornorcotic is safer, for as yet 
the heart muscle and brain cells have not 
been seriously damaged and the brain irri- 
tation is still so mild that it may be control- 
led by a moderate dose of sedative. So in 
brief, the treatment at this stage would be 
to stop alcohol absolutely, to give moderate 
doses of strychnine, or much better, hypo- 
dermics of spartine sulphate, to adminis- 
ter hot liquid food at short intervals, and to 
give one 3l I grain dose of chloral or )\ 
grain of morphine by skin, to which may 
be added 1-150 hyoseine hydrobromate and 
1—500 grain atropin sulphate. If this seda- 
tive dose be preceded by a good sweat the 
conditions are most favorable that the pati- 
ent will sleep, and that the storm may be 
averted. I will emphesize however the im- 
portant point, that while one average nar- 
cotic dose is safe during the pre-delirious 
stage, the same dose with the advent of de- 
lirium, becomes dangerous, moreover, it is 
true wisdom not to push hypnotic or nar- 
cotic medication even during the prodro- 
mel stage. The patient should, of course, 
be kept in his room carefully watched as 
delirum may occur rather unexpectedly. 

Delirious stage: As a rule the physician 
does not see the patient until his conduct 
becomes so abnormal that his friends recog- 
nize the presence of delirium. The irrita- 
tion to the cerebral cortex has now progress- 
ed to the point of active pathologic change. 
There is practically a meningitis and all of 
the patient's unreasonable actions result 
from the cortical irritation. As the cause 
of this irritation is circulating in the blood, 
every reason demands its elimination. To 
add more of the same irritant is but to tax 
further the patient's vital powers. The 
skin, kidneys and only less important, the 
bowels, are the outlets through which we 
must extract the venom. A free initial 
mercurial followed, if at all indicated, by 
a thorcugh saline or ample dose of oil, usu- 
ally needed. The kidneys have already 
been over stimulated for days and any dieu- 
retic given must be of a most unirritating 
character. Fortunately we have in the 
simple, freshly prepared liquor ammonia 
acetatis the ideal drug to stimulate both 
kidneys and skin. It is one drug which 
cannot be abused, which is always safe in 
the treatment of delirium tremens. It meets 
the pathological need of stimulating mildly 
but actively both sudoriferous renal glands, 
while supporting the heaat. < >ne half ounce 
of liquor amonia acetatis may be given 
every two hours with plenty of water. The 

patient should receive liquid diet freqly, 
consisting of milk, butter-milk, milk and 
carbonated water, simple broths and fruit 
juices, which the will usually take even in 
the midst of his delirium if firmly pressed. 
Of oourse it is understood that the patient 
be placed in a safe room and all articles 
dangerous to himself or others be removed, 
razors, pistols, knives, fragile articles and 
any furniture that could be converted into 
a weapon must be taken out of his reach 
and sight. Unless the windows are barri- 
caded or barred there is no safety above 
the ground floor. Isolation from the imme- 
diate family in particular, should be effect- 
ed when practicable. Many incidents oc- 
cur during an attack which can but cause 
pain. Intelligent attendants are essential, 
men who can control the patient firmly but 
kindly . 

In planning our treatment it will be in- 
teresting to note how nature manages the 
case when her powers are not too complete- 
ly paralyzed, by recalling- those cases in 
which the prodromal or early delirious 
stage ends in a spontaneous, profuse pers- 
peration followed by long, deep sleep, con- 
stituting the so-called abortive form of de- 
lirium tremens. So as in the prodromal 
stage, a good sweat bath with the head 
kept carefully cooled by an ice cap and 
the patient's body protected from chilling 
after the bath by a thorough rub down with 
alcohol is a most useful measure. Most 
practitioners will use strychnine in the ef- 
fort to sustain the rapid weak heart, but 
full hypodermics of spartine sulphate ful- 
fill more indications. If, however, the de- 
lerium progresses, and the heart becomes 
more and more rapid until it reaches 130 to 
140, even when the patient is moderately 
quiet, that most admirable agent, the w T et 
sheet pack should be applied. This is my 
dependence in all severe cases, and with it, 
spartine, sweet milk, and liquor ammonia 
acetatis, little more is needed to ideally 
treat this malady. The wet sheet pack 
meets two striking indications; it is a sweat 
bath of prime excellence, and properly ap- 
plied affords that physical restraint which 
becomes necessary in so many cases. I 
find this procedure given in detail in but 
few of our text books, so I may be pardon- 
ed for briefly outlining the application of the 
wet sheet pack. Three double blankets, a 
sheet, wo towels, and eightor ten large safety 
pin sneeded. The three blauknts are spread 
on the bed each one tw T o or three inches 
lower than that beneath. The sheet is 
wrung out of cold water and spread over 
the blankets. If the patient is extremely 
weak and cyanosed, a warm wet sheet is 
used, which is snugly wrapped about him, 
followed in succession by each of the blank- 



ets, the last of which is securely pinned from 
neck to feet, thus keeping the patient from 
disarranging the pack. The head should 
be kept cool with wet towel or ice cap, and 
quantities of liquids given. I have often 
seen patients take a gallon of liquid in 
twenty four hours. The momentary chilli- 
ness will rapidly give place to warmth and 
in fifteen minutes the patient will begin to 
perspire, in many cases the six thicknessss 
of blankets will become saturated in twelve 
hours, if the patient is given plenty of 
liquor ammonia acetates, and water and 
liquid nourishment. In well developed 
cases the patient will continue actively de- 
lirious, and at the end of twelve hours the 
the blankets should be removed and the 
patient rested by a half hour sponge bath, 
water at 96° or much better, a 60 minute 
neutral bath, the patient remaining in the 
tub and temperature of the water main- 
tained at 95°, following this an alcohol rub 
is given and the patient is again ready for 
the pack. I have never had to renew the 
pack more than the fourth time. Usually 
eighteen to twenty-four hours of such ac- 
tive skin elimination will wash from the 
blood sufficient of the irritating poison to 
relieve the cerebral congestion and allow 
the patient to pass into that much desired 
and anxiously awaited "critical" sleep. — 
The odor imparted to the blankets during 
this process of active elimination is such as 
will convince a tyro that something potent 
and foreign is being extracted from the pa- 

The use of copious colonic flushings of 
normal saline solution after removal from 
the pack, greatly augments the efficiency of 
these measures, while with this conception 
of the malady no patient should be denied 
the prompt benefits of free hypodermocly- 
sis of physiologic salt solution upon the 
earliest evidence of failing heart or kidneys. 
Under such treatment a very low death 
rate may be assured. This treatment is, I 
grant troublesome, as compared with the 
deft prick of the hypodermic. But it is a 
treatment which meets the real indications, a 
treatment which produces results, a treat- 
ment which leaves the conscience clear, and 
the treatweut which saves lives. In closing 
I would call attention to the only good I 
have seen result from delirium tremens. In 
treating habit victims I have found no ex- 
perience so potent a converting powers, as a 
frank attack of delirium tremens — a man 
looks, as it were, over the brink, he sees 
his hell' and is glad to be given one more 
opportunity to live a temperate life. 

Vaginal Cyst. -De Beule (Journ. Med. 
de Brux.) describes a case of vaginal cyst 

on which he operated successfully. The 
patient was healthy peasant, aged forty, 
married for about three years, and the moth- 
er of one child. The history was unevent- 
ful until about the age of thirty-four, when, 
on lifting a heavy weight one day she ex- 
perienced a sudden tearing pain in the low- 
er part of the abdomen, nearly turning her 
faint, and obliging her to take to bed. Sev- 
eral days of retention of urine, necessita- 
ting the use of the catheter, followed, but 
in three weeks she was again up and about 
her usual employments. Menstrual troubles, 
present already to a small extent, became 
more accentuated after this, with some dy- 
suria and retention of urine and constipa- 
tion. A tumor appeared at the vulva a few 
months after marriage, disappearing in the 
horizontal position; but at the end of the 
fourth month of pregnancy it disappeared 
altogether until after delivery. Then, how- 
ever, the swelling recurred and gradually 
increased; but this time, however, instead 
of being soft and easily replaced inside the 
vagina, it was hard, elastic, and absolutely 
irreducible. When it came under the notice 
of the surgeon it filled the whole vaginal 
cavity, being about the size of an adult 
fist, with a very broad pedicle, inserted into 
the anterior superior cul-de-sac. Per rec- 
tum, it was felt projecting into the rectal 
ampulla, and rising higher than the fundus 
uteri, which was retroverted. The with- 
drawal by syringe of a citron-colored fluid 
proved it to be a cyst, and operation was 
agreed upon. The tumor was adherent to 
the posterior wall of the bladder in front, 
and behind it was so intimately in relation 
with the peritoneum that a laceration occur- 
red during separation of the adhesions, and 
a loop of the sigmoid flexure prolapsed in- 
to the wound. It was returned, and the 
operation satisfactorily completed, the re- 
sulting urinary disturbances gradually pas- 
sing off. 

The case had been brought to De Beule 
as one of uterine polypus, and, after ascer- 
taining its cystic nature, the next problem 
was to determine its origin. A Wolffian 
and an embryonic starting-point seemed 
both to be contraindicated, as also the 
occlusion of separate glands. From the 
history of the case and the anatomical re- 
lation of the parts, De Beule inclines to the 
view that the strain at the age of thirty- 
four produced a vaginal hernia, withall 'its 
characteristics. disappearing when the preg- 
nant uterus began to rise out of the pelvis. 
The second tumor he regards as a hydrocele 
developed in the empty hernial sac, its char- 
acteristics being analogous to those of a 
hydrocele of the testicle and a cyst of the 



Observations on Pirquet's Tuberculin 
Reaction. —I uigel and Bauer, Munchener 
Medizinisehe Wochenschrift, have tested 
this form of the tuberculin reaction on 
forty-eight infants and two hundred and 
eighty other children. Ths test consists in 
performing a local inoculation with old tu- 
berculin diluted four times. If the result 
is positive a red flat papule appears at the 
site of inoculation at the expiration of 
twenty-four to forty-eight hours. The orig- 
inator of the reaction claimed for absolute 
specificity, and commended it on account 
of its convenience and freedom from dan- 
ger. The authors consider, however, that 
Pirquet's conclusions were founded on in- 
sufficient material, and, although they ad- 
mit there is an intimate relationship between 
the reaction and tuberculosis, they do not 
believe that a positive result is always in- 
dicative of the disease, Of the forty-eight 
infants tested, six gave a positive reaction, 
but five of these appeared from the clinical 
standpoint to be free from tuberculosis. At 
the autopsy on one of these no traces of tub- 
erculosis could be discovered. The other 4 
did not react to a subsequent injection of 
tuberculin. Of the 280 older children, whose 
ages ranged from three to fourteen years, a 
considerable percentage gave a positive re- 
action, and for these these authors believe 
that the test is more reliable. They con- 
clude that the method is of value in mak- 
ing observations on the prevalence of tuber- 
culosis in general, but that in cases pre- 
senting diagnostic difficulties it is not like- 
ly to prove of great service since its results 
are more difficult to interpret than those of 
the- injection of tuberculin. 

gration laws; hence we cannot excuse the 
coming decrepitude. 

Eugenics, if studied with the sole end of 
benefitting our race — coldly, calmly, as be- 
fits the dignity of the subject — will supply 
the remedy. As the Nation says, however, 
"its boundaries are yet too hazy. It attracts 
as votaries men who are prone to slipshod 
thinking and haphazard generalization." 
But every new science labors under this 
disadvantage. Economics, after all these 
years is still hampered by this element, and 
the science of evolution is not yet sufficient- 
ly advanced to shake off the incubus of 
crack-brained enthusiasts. Eugenics will 
grow as a science, because the time has 
come for its development. What has gone 
before in statecraft, in sociology, in medi- 
cine, has been preparatory. And in the 
history of the world the careful student 
will observe that when the times are ripe 
for a new intellectual movement the stimu- 
lus is invariably forth-coming. — Lancet- 

Eugenics. —The new science of eugenics 
is attracting considerable attention among 
the world's thinkers. With the breathless 
haste with which entire nations are pursu- 
ing wealth and what it implies, it is oppor- 
tune that the best minds are devising means 
to check the inevitable degeneracy. Bodily 
fitness is as much required to-day as in the 
davs of medieval prowess. The dominance 
of intellect is as great now as in the golden 
age of Greece. But we live too fast; the 
faculties of the mind are exhausted ere 
they are ripened by experience, the frail 
body succumbs ere it achieves perfection of 
contour. .Men and women are thrown into 
the hopper of modern industrial life and 
come out wrecks. The loss of mental and 
bodily vigor in the majority of a country's 
inhabitants means inevitable deprivation of 
place and prominence in the family of na- 
tions. We would better practice foresight. 
The unfit are no longer permitted to enter 
our portals on account of stringent imnii- 


exists, or has at one time, in fully 50 per 
cent, of our women. Wealth and splendor 
possess no bar to its entrance, it attacks rich 
and poor alike. The woman of leisure is 
even more apt to be afflicted with it than 
her humble domestic, but all in their char- 
acteristic manner, in a measure endeavor 
to keep the fact from their attending physi- 
cian. As said, however, this condition seems 
to be undergoing a change, and these cases 
are daily becoming more frequent to the 
family physician. Dr. J. D. Albright says: 
One of the most troublesome cases I was 
ever called upon to treat was one of ever 
and recurring liability to faint, in a lady 
who formerly had an attack of endometris, 
which had been entirely cured, but which 
left a stubborn leucorrhea in its wake. The 
curing of this trouble has made my patient 
strong, and entirely removed the fainting 
tendency. In a severe case of the combi- 
nation of these two affections, after I had 
exhausted almost the entire materia medica, 
without more than temporary relief, I found 
an excellent remedy in Tyree's Antiseptic 
Powder, which gave immediate relief, and 
resulted in permanent cure. A trial pack- 
age will be mailed free of charge to phy- 
sicians if they will send their name and 
address to Mr. J. S. Tyree, Chemist, 
Washington, D. C. 



Charlotte Medical Journal 

No. 36 South Tkyon Street. - - - - 
- - Charlotte, N. C. 


Ten years ago the Tri-State (Virginia 
and the Carolinas) Medical Association was 
organized and held its first meeting in Char- 
lotte, Since that time both the Queen City 
and the Association have prospered and 
grown. And but recently, on the 18th of 
February, 1908, the tenth annual meeting 
of this body was held in Charlotte, and the 
Tournal takes pride in saying that it was a 
most successful meeting, a meeting well at- 
tended and full of interest from first to last. 
It is said that it has been one of the largest 
and most enthusiastic meetings that the 
Association has ever held, and in this state- 
ment we find special pleasure. 

Charlotte is an ideal place for gather- 
ings of this kind, Centrally located it is 
also accessible to the members, and the 
hotel facilities are admirable, as is evi- 
denced by the manifold expressions on the 
part of those attending. And beyond all 
this, we, of Charlotte, find the very greatest 
delight in our efforts to entertain those who 
honor us by their presence. 

The Selwyn Hotel was made headquar- 
ters for the Association and in its assembly 
hall the Society was called to order at 10 
o'clock, Tuesday morning, Feb. 18, by Dr. 
E. C. Register, Vice President, and chair- 
man of the local committee on arrange- 
ments. Rev. W. M. Kincaid, D. D., 
offered prayer, after which the chair intro- 
duced Mr. D. A. Tompkins, of Charlotte, 
who made the address of welcome on behalf 
of the city. He spoke in reference to the 
progress and developments of the medical 
profession and its co-operation with sani- 
tary engineering. His remarks were of 
more than ordinary significance and in 
direct sympathy with the work of the medi- 
cal profession. 

Seldom does one have the privilege of 
hearing an address equal in merit to the 
response made by Dr. J, W. Jervey, of 
Greenville, S. C, to the speech of Mr. 
Tompkins. Thoughrful, scientific and well 
worded, Dr. Jervey's exposition of the prin- 
ciples which actuate the medical profession 
presents the physician in a new and unusual 
light. His fundamental proposition was 
that: "Medicine lives by just those things 
which it seeks to eradicate." 

Dr. Stuart McGuire of Richmond, Va., 
was then introduced and as president-elect, 

took the Chair. In his address, Dr. Mc- 
Guire traced the history of the Tri-State 
Medical Society from its origin in 1898, 
through all its vicissitudes of opposition to 
the present successful and enthusiastic 
organization. He had much of interest to 
say in regard to the achievements of the 
Association, its place as a medical society, 
and its aims. 

Following these preliminary exercises the 
reading of papers was begun. On the pro- 
gram were the names of nearly one hun- 
dred doctors, and most of them read papers. 
The list was unusually large, and many of 
the papers were especially noteworthy. The 
subject of the annual debate was, "The 
Treatment of Epilepsy." Dr. J. Allison 
Hodges' paper on Epilepsy was excellent, 
thoroughly up to date — indeed in advance 
of most ideas which prevail concerning the 
best methods of treatment. Dr. J. P. Mun- 
roe discussed the subject in his character- 
istically eloquent and learned manner. 

A number of physicians of national and 
international reputation were guests of the 
Association. Among these were Drs. W. 
B. Pritchard, Chetwood, A. Ii. Goelet and 
J. A. Bodine of New York City, L. F. Bar- 
ker of Johns Hopkins, C. A. L, Reed of 
Cincinnati, and H. A. Hare of Philadel- 
phia. Papers presented by these distin- 
guished gentlemen were heard with the 
closest attention. In a great many cases 
visitors come to the medical society meet- 
ings removed from the large cities by great 
distances for no other purpose than to ad- 
vertise some special method or hobby of 
their own, to describe some operation so 
intricate and impossible of understanding 
that the country doctor, the average sur- 
geon in small towns, finds little value or 
interest in them. In marked contrast to 
this rule were the papers by the visiting 
physicians and surgeons mentioned above. 
All of them had something to say and they 
said it in such manner thaf it was clear and 
concise — valuable information, all of it. 
The speech of Dr. Reed of Cincinnati, who 
confessedly aspires to succeed the Honor- 
able and widely notable Foraker as United 
States Senator from Ohio, showed how 
little part is taken by medical men in poli- 
tics, how few are numbered among the law- 
makers of our nation. He appealed to the 
profession to assert itself and assume a 
larger participation in the affairs of the 

The reception at the Selwyn Hotel Tues- 
day night, February 18, was a most elab- 
orate and enjoyable sociable event. In 
every particular, it was all that such a func- 
tion should be to be characterized as ele- 
gant and delightful. During the hours 
from 9:30 to 11:30 o'clock several hundred 



guest were entertained, and the cordial hos- 
pitality extended by the reception commit- 
tee could not have been surpassed. 

The refreshments of salad, ices, cake 
and punch, were of the qnality and were 
served in the manner that was entirely in 
keeping with the occasion. 

Nothing was left undone in making this 
reception all that it shuld have been, and 
combined with its elegance there was that 
delightful informality which made it all the 
more pleasing. 

The election of officers for the ensuing 
year resulted as follows: 

President, Dr. Albert Anderson, of Ral- 
eigh: Nice- Presidents, Dr. R. C. Bryan, of 
Richmond, Va.; Dr. J. K. Stokes, of Salis- 
bury: Dr. W. P. Timmerman, of Bates- 
burg, S. C; Secretary-Treasurer, Dr. J. 
Howell Way, of Waynesville. 

The following were elected to serve on 
the executive council in addition to those 
already constituting its membership: Drs. 
K. G. Williams, of Richmond, Ya.; A. J. 
Crowell, of Charlotte, and A. E. Baker, of 
Charleston; S. C. 

Fifty-seven doctors asked for admission 
into the Association and all were received 
into membership. Charleston, S, C, was 
selected as tde place where the meeting will 
be held in 1909. 

Between one hundred and seventy-five 

Tubercular Peritonitis?" by Dr. David A. 
Stanton, of High Point, N. C. 

"Tuberculosis of the Uterus and its Ad- 
uexae" by Dr. A. K. Baker, of Charleston, 
S. C. 

"Nasal Obstructions and Nasal Pressure; 
their Etiological Connection With Various 
Pathological Conditions," by Dr. Joseph 
A. While, of Richmond, Va. 

"Complications of Chronic Suppuration 
of the Middle Ear, With Special Reference 
to Sinus Thrombosis," by Dr. Frank M. 
Cunningham, of Macon, Ga. 

"Report of Interesting Cases," by Dr. 
E. W. Carpenter, of Greenville, S. C. 

"Symptoms and Treatment of LaGrippe" 
by Dr. F. D. Drewry, of Virgilina, Va. 

"Some Phases of Neurological Syphilis," 
by Dr. William Broadus Pritchard, of New 
York City. 

"Recent Progress in the Study of Ty- 
phoid Fever," by Dr. Lewellys F, Barker' 
of Baltimore, Md. 

"Amoebic Dysentery in the Southern 
United States," by Dr. Thomas R. Boggs, 
of Baltimore, Md. 

"Some Illustrations of X-Ray Work," by 
Dr. Ennion G.Williams, of Richmond, Ya. 

"The General Attitude of the X-Ray, of 
Richmond, Ya. 

"The New Electrical Currents in the 
Treatment of Nervous Diseases," by Dr. 

and two hundred physicians attended the Charles M. Hazen, of Richmond, Ya. 

sessions during the two days of the meet- 
ing. These came chiefly from the Caro- 
linas and Virginia. In every way the Tri- 
State Association is to be encouraged. It 
is a healthful body of scientific doctors and 
a finer set of men has not been seen in Char- 

A partial list of the papers read is here- 
with presented; 

"Inebriety: A Variety of Comments," by 
Dr. S. M. Crowell, of Charlotte. 

"The Study of the Eye as an aid to Diag- 
nosis of Systemic Diseases," by Dr. Leland 
* ). Mauldin, of Greenville, S. C. 

"Some Pertinent Points on the Proper 
Control and Examination of a Sick Child," 
by Dr. G. \V. Cocke, of Danville, Va. 

"Confusion and Errors in the Diagnosis 
of Rheumatism," by Dr. Lewis M. Gaines, 
of Wake Forest. 

"A further Report of Tuberculosis Cases 
from 1898 to 1906," by Dr. J. A. Bur- 
roughs, of Asheville. 

'Tuberculinum in Pulmonary Tubercu- 
losis — With Particular Reference to the 
Administration of Dosage and Deny 's Tu- 
berculinum," by Dr. Raul Ringer, of Ashe- 

"Renal Tuberculosis," by Dr. I.eGraud 
Guerry, of Columbia, S. C. 

"What Shall We Do With ( >ur Cases of 

"The Present Status of Therapeutics," 
by Dr. John C. Walton, of Chase City, Ya. 

"Local Anaesthesia, by Dr. John A. 
Williams, of Greensboro. 

"Tetanus," by Dr. Charles T. Harper, 
of Wilmington. 

"My Personal Experiences in Treating 
Appendicitis," by Dr. Joseph Graham, of 
Durham, N. C. 

"The Treatment of Epilepsy," by Dr. 
Allison Hodges, of Richmond, Ya. 

"Epilepsy — The Idiopathic Form." by 
Dr. Beverly R. Tucker, of Richmond, Va. 

"The Study of 105 Hysterectomies," by 
Dr. A. Murat Willis, of Richmond, Ya. 

"The Ureter — Some Considerations," by 
Dr. Robert C. Bryan, of Richmond. 

"Etiology and Treatment of Hypertrophy 
of the Prostate Gland," by Dr. A. J. Cro- 
well, of Charlotte. 

"Prostatic Hypertrophy, " by Dr. Chas. 
H. Chetwood. of New York City. 

"Some Points in Technique of Breast 
Amputation," by Dr. John A. Bodine, New 
York City. 

"Retained Placenta; Report of Cases 
With Remarks," by Dr. John R. Upshur, 
of Richmond, Va. 

"Unusual Cases of Ovarian Cyst," by 
Dr. II. Stuart McLean, of Richmond, Va. 

"Ectopic Gestation: Report of a Case," 



by Dr. John W. Dillard, of Lynchburg, Va. 

"The Treatment of Endometritis by Irri- 
gation and Drainage, " by Dr. A. H. Goelet, 
of New York City. 

"The Treatment of Bright's Disease," 
by Dr. Benjamin K. Hayes, of Oxford. 

"Retention of Urine and Its Relief," by 
Dr. Owen Smith, of Asheville. 

"Report of a Case of Sarcoma of Colon," 
by Dr. C. M. Strong, of Charlotte. 

"Open Method of Treatment of Epitheli- 
omata on Muco-Cutaneous Surfaces," by 
Dr. W. D. Witherbee, of Charlotte. 

"The Out and Indoor Treatment of Tuber- 
culosis — Illustrations of Methods and the 
Principles Involved," by Dr. Paul Paquin, 
of Asheville, N. C. 


One hears a great deal these days, as has 
been the case for so many years that it 
passeth the memory of man, about the 
cruelty, the utter heartlessness of, and the 
lack of any necessity for vivisection. Sev- 
eral years ago the American Humane Edu- 
cation Society offered a prize of two hundred 
and fifty dollars for the best essay in favor 
of vivisection and a like sum for the best 
essay against the practice. In 1906 they 
again offered two prizes of three hundred 
dollars each to be awarded in a similar 
manner, and the reason assigned for this 
last contest was the fact that a street in that 
classic birth place of all American hobbies, 
Boston, had been named in honor of the 
great French scientist and investigator, 
Louis Pasteur. Unmindful of all the bene- 
factions of a great man to humanity, forget- 
ful of all the knowledge that his investiga- 
tions have given to the world, these New 
England extremists have found a reason in 
the fact that Pasteur was a vivisectionist to 
protest against his name being given to a 
Bostonian avenue. 

As a result of the contest, the prize for 
the best essay against vivisection has been 
awarded to a woman whose knowledge of 
the practice is as limited as her prejudice is 
wide, and whose disregard of the benefits 
which have accrued to mankind from vivi- 
section is as palpable as her ideas are 

The question whether vivisection is so 
cruel as to overbalance its value in adding 
to the knowledge which shall ultimately 
give to men the control of disease is the real 
point at issue. Anti-vivisectiouists, in their 
rampant zeal, would put an end absolutely 
to the practice. They select a few isolated 
instances in which there seems to have been 
unnecessary cruelty practiced on the animals 
used in experimentation ; they see the writh- 
ings, hear the whine of a frightened animal 
and straightway the human lives which 

have been saved, the years added to the 
sum of life of mankind, all this is blotted 
out in the swift call for vengeance on him 
who would dare prick a mouse with a 
needle. There seems to be a total disregard 
of the agonies suffered by animals sacrificed 
to satisfy the demands of the human appe- 
tite for food, in comparison with which the 
sufferings of vivisected animals are as noth- 
ing. But it is said that animal food is 
necessary to men and that the slaughter of 
animals cannot be obviated: that is one of 
the exigencies of life. Man's success in 
the struggle for existence — for life is a strug- 
gle, a struggle with fellowmen, with living 
beings, animals and plants, and with the 
lifeless forces around us — depends upon 
superior knowledge. He must be fed; he is 
justified in killing and eating animals which 
will furnish food for his sustenance. He is 
equally justifiable when he kills a frog, a 
rabbit or a dog, if thereby he adds to the 
sum of human knowledge, and thus enables 
men successfully to combat the ravages of 
disease. It is not difficult to understand 
that vivisection is justifable when one re- 
views the vast range of the discoveries due 
to this practice alone. It is safe to assert 
that men would still be groping in the dark- 
ness and ignorance of medievalism when 
as little was known as was possibly by sen- 
tient beings. Anatomy, physiology, pa- 
thology, bacteriology actually depend upon 
vivisection for such advance as has been 
accomplished in these studies. Information 
concerning many of the diseases most deadly 
to mankind and a knowledge of them such 
as have given men the means- and power to 
control them, have been found largely by 
animal experimentation. Truly this essen- 
tial knowledge might have come after long 
years of observation and after the unneces- 
sary sacrifice of thousands, even millions, 
of human lives. Yet even granting that 
this knowledge could have been arrived at 
in some other way, any broad-minded, right- 
thinking person must confess that it were 
better to sacrifice the lower, less valuable 
life in order that human beings may be 

The anti-vivisectionist finds and selects 
for purposes of carrying his point instances 
— some of them true, others perhaps utterly 
unsubstantiated — in which the vivisector 
employed methods unnecessarily crude and 
inhuman, yet even these were to a certain 
extent justified if thereby knowledge was 
gained. If no good resulted from the prac- 
tices we do not in any way consider the ex- 
perimenter to have been justified. In prac- 
tically all cases the animal is entirely un- 
conscious, insensible to pain and therefore 
cannot suffer. The experimenter is never 
justified in causing pain if it can be avoided, 



unless the pain is of advantage to him' 
Instances such as that of which so much 
was made several months since, when in 
one of the Western schools it was said a dog 
used in some vivisecting experiment was 
turned loose in the streets maimed and 
mutilated and left to suffer agonies as a 
consequence, have been turned to good use 
by the anti-vivisectiouist. Such instances, 
if genuine, are wrong and indeed cruelly 
unnecessary . Vet there is no justice in con- 
demning the whole practice and saying that 
this is quite a common occurrence because 
these few instances can be cited. 

It is said that curare — a drug which para- 
lyzes the motor nerve endings but leaves 
the sensory nerves unaffected — is in com- 
mon use in laboratories. As a matter of 
fact it is not used to any great extent, and 
yet we claim that even its use is justified if 
the condition produced by it is of advantage 
to the investigator. 

However, this is not intended as an at- 
tempt to refute the arguments of the anti- 
vivisectionist. More space than is available 
would be required for a thorough considera- 
tion of the subject. It simply seems to us 
unreasonable and absurd that people can 
so zealously oppose a practice which has 
helped to clear up so many dark problems 
for mankind, which has resulted in such 
vast good for the human race. The fact 
that the few instances of unnecessary cruelty 
can be adduced as arguments against it 
deserve consideration only when weighed 
against the genuinely beneficent results of 
vivisection. If the latter can be shown to 
overbalance the former — and to an unpreju- 
diced mind this is not difficult — then the 
cause for vivisection is perfectly clear. For 
a very scholarly exposition of facts favor- 
ing vivisection the reader is referred to an 
essay by Andrew McPhail, B.A., M.D., of 
Montreal, published in the January issue of 
"Our Dumb Animals." Contrast it with 
the essay against vivisection by Miss Lena 
A. Britton, of Vermont, appearing in the 
same issue of the above named paper. 


The management of the Charlotte Sana- 
torium, soon 1<> be opened in this city, the 
erection of which is now rapidly progress- 
ing, have issued a very neat folder descrip- 
tive of the Nurse's Training School, which 
will be one of its best and most attractive 
features. Elsewhere appears an advertise- 
ment giving a brief description of the sana- 
torium and previously we have made men- 
tion of it in these pages. A great many 
hospitals in the South — perhaps the majori- 
ty of them — have connected with them a 
training school for nurses and many of 

them are graduating young women who, as 
trained nurses, adorn as noble a profession 
as the sun shines on. The Charlotte Sana- 
torium will be as complete a hospital as 
exists in the South anywhere. A modern 
building designed and erected under the 
most advanced ideas which govern the 
architecture of hospitals, will enable the 
faculty to put into practice every well- 
recognized therapeutic method, and to do 
the very best work medical men can do. 
All these things mean that the nurse must 
have special advantages of training which 
she could not get in a hospital less modern 
and up-to-date. Hospitals have developed 
wonderfully within recent years; every town 
of a few thousand inhabitants must now 
possess an institution of this kind. And 
along with this development of the hospital 
the nurse has developed also until today 
she is indispensable, a necessity. The mod- 
ern doctor is, in a certain sense, helpless 
without her. 

The Charlotte Sanatorium will be equip- 
ped with the latest hydrotherapeutic and 
electric apparatus, sun parlors, two operat- 
ing rooms, electric elevators, vacuum clean- 
ing system and private telephones. 

The town offers most excellent advant- 
ages for such a hospital. A city of forty 
thousand inhabitants and rapidly growing, 
no town in the South has before it a brighter 
future than Charlotte. 

The Training School for Nurses will con- 
sist of a Superintendent and corps of forty 
nurses. The Faculty will be composed of 
the following doctors: 

Medicine, Kdw. C. Register, M. D., J. P. 
Munroe, M. D.; Disease of Digestion, W. 
O. Nisbet, M. D.; Surgerv, G. W. Presslv, 
M. D., C. M. Strong, M. D.; Eve, Far, 
Nose and Throat, E. R. Russell, M. I)., A. 
M. Whisnant, M. D.; Genito-Uurinary and 
Rectal Diseases, A. J. Crowell, M. D.; 
Cancer and Skin Diseases, W. D. Wither- 
bee, M. D. 

The course of instruction consists of a 
period of three years. Lectures on the fol- 
lowing branches will be given by the mem- 
bers of the staff: Materia Medica; Anat- 
omy; Physiology; Fever Nursing; Obstetrics 
and Gynaecology Hygiene; Accidents and 
Emergencies; Practical Nursing. 

Each nurse before graduation will have 
had a thorough, practical training in the 
following departments: Medicine; Hydro- 
therapy; Massage; Surgery; Eye, Ear, Nose 
and Throat; Nervous Diseases; Diseases of 
Digestion; Genito- Urinary and Rectal Dis- 
eases; and Iilectro-Therapy. 

Lectures will be given every night from 
eight to nine p. m. 

It is especially desired that nurses will 
make application for training in the Char- 



lotte Sanatorium who have had some ex- 
p2rience in other hospitals. They will be 
given credit for previous training. A fea- 
ture which is somewhat unusual in this 
section, but which will doubtless prove 
very attractive, is the fact that nurses will 
not be furnished board or rooms in the 
hospital. They will be paid a salary suffic- 
ient to permit them to find comfortable lodg- 
ing where they may choose. 

Dr. W. D. Witherbee or Dr. E. C. Regis- 
ter, of Charlotte, will take pleasure in mail- 
ing to those who may desire it an attractive 
folder containing a description of the hos- 
pital and its equipment, rules and regula- 
tions for nurses and an application blank 
for use by those who wish to send in their 


One of the most highly instructive, among 
the very numerous papers of great excel- 
lence read before the recent meeting of the 
Tri-State Medical Society, was that present- 
ed by Dr. Thos. R. Boggs, of Johns Hopkins, 
on the subject of Amebic Dysentery. A 
good many years ago Osier, in his "Practice 
of Medicine' ' made the assertion that amebic 
dysentery is the most common form in this 
region — referring to Baltimore and environs. 
Certainly it more frequently occurs than is 
supposed. Not one doctor in a thousand 
ever takes the trouble to examine or have 
examined the stools of patients suffering 
from diarrhceal diseases of the intestine. 
When a patient has dysentery, the clinical 
diagnosis is made and therapeutic measures 
of greater or less efficiency are adopted in 
the effort to cure the disease. Does the 
doctor ever know the cause of the disease 
with which he is dealing? Is he able to say 
whether he has a case of amebic dysentery 
or a case of dysentery caused by the bacil- 
lus of Shiga or by some other pathogenic 
micro-organism? Not unless he has, in con- 
nection with his clinical observations, made 
or had made a microscopic examination of 
the stools. By this means it is possible to 
say positively whether amebae are present 
and if present whether they are pathogenic 
or non-pathogenic, i.e., whether the case is 
or is not caused by the amebae. To be able 
to do this does not require especially great 
skill as a pathologist or microscopist, nor is 
it so time consuming as to offset its value to 
the general practitioner. On the other hand 
the great satisfaction which comes to one in 
being able to make an exact diagnosis is 
worth the trouble; and really the difference 
in methods of therapy to be adopted accord- 
ing to whether amebae are or are not found 
will in results more than repay the prac- 

According to the latest authorities two 

varieties of amebae inhabiting the human 
intestine are described and in order to dis- 
tinguish them the names ameba dysenteriae 
and atneba coli have been applied to the 
pathogenic and non-pathogenic varieties 
respectively (Councilman and Lafleur.). 
Other investigators nave described other 
varieties, celli and Fiocca, giving six which 
they say are found in the human intestine. 
Without attempting to enumerate and de- 
scribe these numerous varieties, which only 
complicates the subject, we shall try to lay 
down a few simple rules by which the patho- 
genic and non-pathogenic may be differ- 
entiated. Primarily this differentiation was 
based upon the effect produced upon cats 
by inoculation. One species proving patho- 
genic, the other non-pathogenic for these 
animals. It was observed that amebae 
found in the discharge of dysenteric patients 
produced typical lesions in cats, while 
ameboe found in the stools of individuals 
apparently showing no signs of dysentery 
produced no lesions. Now while one could 
scarcely employ this test for pathogenicity 
in every case, it nevertheless has enabled 
the differentiation to be the more easily 
made by other means. But first of all 
should be given some of the general charac- 
teristics of amebae. "They are classed as 
rhizopoda of the protozoa. They are uni- 
cellular parasites possessing an endosarc 
and ectosarc which can readily be distin- 
guished when the organism is in motion. 
The endosarc is granular, and usually en- 
closes several vacuoles of variable size. The 
ectosarc is clear and more hyaline in ap- 

"The parasite moves by means of pseudo- 
podia; blunt processes consisting of the 
ectosarc are first protruded and into these 
protrusions the protoplasm of the endosarc 
appears to flow. The organism is capable 
of changing not only its shape but also its 
position and so moves about. It possesses 
a nucleus which may sometimes be observed 
in the living forms, but which can be more 
clearly seen in colored preparations. It is 
usually placed eccentrically in the endosarc 
and contains a nucleolus." 

"The diameter of these organisms has 
been variously estimated at from 10 to 50 
micra. While they may vary greatly in 
size in different cases, in the same one they 
are usually of a fairly uniform diameter. 
Sometimes in stools that have remained 
standing for some time, the amebae become 
encysted. They then appear to be sur- 
rounded by a coating of two layers, and it 
is sometimes almost impossible to differen- 
tiate them morphologically from other sub- 
stances. The outer layer of the cyst fre- 
quently presents a warty appearance." 



Amebae are extremely difficult to grow 
in pure culture on artificial culture media. 
So difficult, indeed, that it is extremely 
doubtful whether it has ever been accom- 
plished, although Kartulis,Celli and Fiocca, 
and Tsujitani claim to have succeeded in 
doing' so. Musgrave finds them more easily 
cultivated along with other bacteria. 

To return now to the differentiation of 
pathogenic and non-pathogenic species — 
one of the most striking points is the dis- 
tinction between the eudosarc (inner gran- 
ular zone) and ectosarc (outer clear, non- 
granular zone) of the protoplasm. In the 
dysenteric amebathis is distinct and clearly 
defined, while in the harmless one it is not 
so readily made out, the protoplasm of the 
ectosarc being not nearly so refractive. In 
the pathogenic organism the nucleus is 
placed more eccentrically and is to be seen 
be6t in stained preparations; in the non- 
pathogenic variety the nucleus is small, 
compact and more readily observed when 
unstained than is the former. A very im- 
portant distinction, and perhaps the point 
to be most considered, is the fact that red 
blood corfuscles are to be seen in the 
amebae dysenteriae while they are never 
seen in amebae coli. The former are usually 
larger, varying from 35 to 50 micra in 
diameter, while the latter rarely exceed 25 
micra. This point is, however, not to be 
relied upon since numerous observers have 
reported very small amebae as the only 
parasites present in undoubted cases of 
amebic dysentery. 

If the practitioner but keeps in mind the 
characteristics of amebae which exist in the 
human intestine he will find little difficulty 
in saying whether they are present in any 
given case, provided he have the patience 
to consume a few minutes in examining the 
stools. Then having determined their pres- 
ence it will not be especially difficult to dif- 
ferentiate the harmful from the harmless. 
It is only necessary to look for the sharply 
defined zones of endo- and ectosarc, the 
indistinct, eccentrically placed nucleus and 
the presence in the ameba of red blood 

If physicians would take the trouble to 
study cases with a view to gaining a genu- 
inely accurate knowledge of the case, its 
causes, &c, the sum of scientific knowledge 
would be vastly increased. The fact that 
one scientific man — although he may be the 
very highest authority — has said that in 
these latitudes amebic dysentery is the most 
common form does not prove it. It may be 
extremely common and yet relatively rare. 
Who knows? We wish that doctors could 
be stimulated to a proper interest in such 
questions. If one man, or half a dozen 
men, in any particular community would 

actually set about making a complete study 
of any one clinical entity and keeping ac- 
curate records thereof, there is no way of 
telling what might be the result. Contribu- 
tions to human knowledge are made in just 
this way. A man need not say that he has 
not the opportunity or the appliances neces- 
sary. Great things have been accomplished 
far away from the finely equipped labora- 
tories and hospitals of the large medical 


The Journal wishes to acknowledge re- 
ceipt of the Eleventh Biennial report of the 
North Carolina Board of Health, an inter- 
esting volume containing much information 
of what is being done by this excellent 
body. Dr. Lewis, the able secretary of the 
Board, has accomplished his work with 
thoroughness and detail as great as is pos- 
sible. Of especial interest to us in Charlotte 
is the full report of the investigation of the 
Typhoid Fever Epidemic which occurred 
in this city in 1906, or we should perhaps 
say that special portion of the epidemic con- 
fined to Elizabeth College. 

The secretary is a most capable officer, 
painstaking and thorough in his work. 


Down in Georgia the ministrations of an 
osteopath seems to have so worn on the 
nerves of a patient(?) that he (the patient) 
was compelled — so he says — to shoot the 
doctor in order to get rid of his attentions. 

The osteopath, Dr. L. F. Powers, of 
Columbus, Ga., was shot and probably 
fatally wounded by Ed Powers. We have 
not heard the outcome of the case. 


A magnificent gift for the benefit of 
humanity is the hospital to be built by Mr. 
Geo. W. Watts and given to his home city, 
Durham, N. C. A man of most generous 
and philanthropic spirit, Mr. Watts is well 
known throughout the State for his mu- 
nificence. But of all his good works none 
deserve so great commendation as this gift 
to build and endow a modern, up-to-date, 
charity hospital, an institution badly needed 
in that portion of the State. 

The plans have been drawn by the great- 
est hospital architect in this country and 
the contracts were opened about March 1st. 
According to the plans the buildings will 
be so erected that additions can be made in 
future years without in any way altering 
the original plan or losing the work already 
done. The buildings for which contracts 
have been let will cost from $150,000 to 
$200,000. They will be fire-proof, of the 
latest and most approved construction and 



fitted with every convenience demanded in scribe it as a remedial agent. The dil'fer- 
modern hospitals. ences of doctors regarding the therapeutic 

The buildings are to be located just north- properties of alcohol are notorious. One 
west of the city limits on a tract containing set will say that it has no place as a remedy 
50 or 60 acres. Wide streets are being laid in the pharmacopoeia, that it is only a 
off and macadamized about the property. poison and that it should never be used 

Years ago Mr. Watts gave to Durham a under any circumstances; others take the 
small hospital which has been known as the opposite view, holding that it is a most use- 
Watts Hospital, and which has been a source ful drug, a tissue builder and support and 
of great good to the town and community, that there are many conditions in which it 
We are told that he has given half a million is absolutely indicated. And between these 
for this new structure. Truly a princely extremes are those whose views are more 
gift and a lasting monument to his gener- moderate. Everybody is aware, or at least 
osity. The doctors of Durham are most believes, that there are physicians who will 
fortunate, for such an institution is a boon and do abuse the trust imposed upon them, 

lot only to humanity but to the physician. 

now WIEL. iT WORK! 

At a recent meeting of the Wake County 
Medical Society the members adopted 

that they, in many instances write whiskey 
prescriptions for the money there is in it 
when they know it is not necessary for 
them to do it, when no drug at all is needed. 
Still taking any individual case in which 

resolution finding its origin in the belief the person for whom the whiskey was pre- 

that inasmuch as the recent prohibition scribed makes a wrong use of it, will it be 

election in Raleigh, N. C, makes the phy- possible to hold the physician responsible? 

sicians entirely responsible for the sale of Morally he may have done wrong to give a 

whiskey in Wake county and that it would prescription for alcoholic stimulant, pro- 

therefore be unprofessional and unethical vided he was not confronted with an abso- 

to write whiskey prescriptions for other than lute indication therefor, and yet, as we said 

remedial and therapeutic purposes. Any above, it is simply a question of his own 

doctor violating this high privilege by writ- conscientious regard for duty and the right, 

ing prescriptions for whiskey for people Manifestly it is a problem, the regulation 

whose physical condition does not strictly of which possesses most serious difficulties. 

indicate and demand its use will be consid- 
ered to have given sufficient grounds for 
causing the revoking of his license. 

Now we believe that no countv in North 

Its solution has not yet been accomplished 
and we believe the solution is still to be 
realized. However, we reiterate our con- 
gratulations to the Wake county doctors 

Carolina possesses a body of physicians because of the stand they have taken in 
more honorable or high minded than those this matter. If it accomplishes any good 

is worth the attempt. 


Two cases of yellow fever have been re- 

found in the countv of Wake, and we be- 
lieve also that the sentiment involved in the 
resolution above mentioned is entirely cor- 
rect and pure in the motives which inspire 

it. And vet in the matter of prescribing it ported at Galveston, Texas. They arrived 

is left entirely with the physician's own on a steamship from Brazil which during 

sense of honor and right as to whether he its passage had five cases on board. Ouar- 

shall or shall not write a prescription for antine measures will doubtless prove effec- 

whiskev in any individual case. Ifhesa.vs tive in preventing the disease gaining a 

that he considers it necessary for a certain foothold in the port of Galveston, 
person to have whiskev, who can gainsay ^^ „_ _ „,„ TM 

his right to prescribe it? Certainly not the c nvccm dbbmata .. h 
laymen, for whatever may be his beliefs in " authentic the case of the birth of quin- 

the matter, after all it is more or less a mat- triplets to a woman m Steuben sville, Ohio 

ter of prejudice with him. If he can say is extremely interesting to physicians and 

the physician shall not give whiskey in one certainly remarkable. It is said that three 

case that abrogates the right in any case. of the bab i e s died soon after birth, but that 
And if the doctor may not prescribe one wm Hve Therg were three boys and 

remedial agent what becomes of his rights 

as a physician? Take away one of his two girls, all perfectly formed, and their 

weapons against disease and logically the combined weight was twenty-three pounds. 

law has the right to say whether he shall or Ti ie mother weighed less than one hundred 

shall not use any other drug or, for that poun( j Si 

matter, all of them. Nor can other phy- 
sicians justly say another doctor did or did 
not have the right to prescribe whiskey or 
to say whether it was his purpose to pre- 

We wonder what was the state of mind 
of the father when he saw this vast increase 
o his family. 




The town of Durham is to be commended 
in the efforts being made there to stamp out 
the dread disease tuberculosis. The health 
authorities of that city are making arrange- 
ments for an organized fight against the 
great white plague. Every inch of ground 
is to be contested and the people are to be 
given a campaign of education in order to 
enlist them in the work, for without the co- 
operation of the people at large the attempt 
is hopeless. A mass meeting will be held 
at which time tuberculosis will be the sub- 
ject of discussion. 

DR. L. L. ftRDBBY. 

We are grieved to record the death of Dr. 
Lucius L. Ardrey who passed away Febru- 
ary 12, 1 90S, at his home in Bandera, Texas. 
Dr. Ardrey has been desperately ill for many 
weeks and little hope has been entertained 
for his recovery. A native of Mecklenburg 
county, North Carolina, Dr. Ardrey left his 
home State several years since hoping that 
he would be benefited by the Texas climate 
and at times he had shown improvement. 
His remains were brought to his old home 
near Pineville, X. C, for interment. 

Dr. Ardrey was a graduate of Bellevue 
Hospital Medical School, class 1896. 


Small-pox is reported to be raging in 
Wilkes county. It is said that considerable 
excitement prevails, several cases having 
proved fatal. A strict quarantine has been 
established but in spite of precautions the 
disease has spread over a considerable terri- 
tory, embracing portions of Wilkes, Iredell 
and Yadkin counties. 

Dr. T. E. Armstrong, formerly of South 
Boston, Va., has moved to Canton, N. C, 
the thriving town which has grown up 
around the Champion Fibre Company. 

Dr. J. M. Flippin, an active practitioner 
for the past twelve years in Salisbury, will 
in a few weeks remove to Oklahoma City, 
Oklahoma, where he will locate. 

The Medical Society of the State of North 
Carolina will meet in Winston-Salem, June 
lo-19, 1908. This change of date is prob- 
ably not generally known among members. 
We therefore call attention thereto. 

The Journal takes pleasure in acknowledg- 
ing the announcement that Dr. Beverly R. 
Tucker has located in Richmond, Virginia, 
where lie will confine his practice to Nervous 
and Mental Diseases. He can be found at 
402 West Grace Street. 

The Bickett Commission having decided 

to erect at Morganton, N. C, a Nurses' 
Building have recently chosen plans drawn 
by Barrett & Thompson, of Raleigh. The 
building will cost $25,000 and by removing 
the nurses from the main building will give 
room for one hundred more patients. 

Review of Southern Medical Literature 

The American Practioner and News, Jan. 
J 90S. 

Typhoid Fever In Children.— Dr. P. F. 

Barbour believes that many of the cases of 
so-called bilious remittent fever or continu- 
ed fevers with no focalizing symptoms 
would now be called typhoid. It is safe to 
call any continued rebelious fever in chil- 
dren tvphoid, until the true nature is proved. 
Laboratory methods will enable one to diag- 
nose enteric fever with scientific accuracy. 
The Widal serum test is conclusive in over 
ninety-five per cent, of cases. The isola- 
tion of the bacilli from the blood, urine or 
feces, will settle any doubts. Ehrlich's 
diazo reaction has often been helpful and is 
obtained before the serum test is applicable. 
A blood count is of great assistance, for 
there is a marked diminution in the hemo- 
globin, and especially characteristic is the 
marked leucopenia. None of these meas- 
ures, however, are practicable unless a 
trained microscopist and bacteriologist is at 
hand, and for the average practitioner they 
require too much time. One must rely in 
most cases upon the objective symptoms, 
such as the character, persistence and height 
of the temperature, headache, delirium, 
epistaxis, rose spots, enlarged spleen, the 
pulse, sensitiveness of the abdominal wall 
or the inner side of the thigh to pressure, 
the stools, etc. Tuberculosis is the only 
disease which at times makes differentiation 
difficult, but its course is different and the 
prognosis here is absolutely grave, while in 
typhoid fever the mortality in children under 
five probably will not exceed two per cent. 
In the treatment of this disease the author 
has derived most satisfaction from combin- 
ing salines with antiseptics, such as sulpho- 
carbolates. There can be no advantage in 
retaining in the intestinal canal a putrifying 
mass, the toxines from which are being 
absorbed and are overtaxing those organs 
which must handle and eliminate these 
deleterious and noxious substances. While 
it is impossible to administer an antiseptic 
which will enter the blood stream and attack 
the Eberth's bacillus, yet such as are in the 
intestinal tract, together with great numbers 
of other pathogenic bacteria, can be reached 
and actually inhibited or destroyed. Clinical 
experience has convinced the author that 
where the motto was to "clean out and keep 



clean" all the unpleasant symptoms were 
mitigated and the cases pursued a much 
milder course. Children when treated along 
this line will not have the high temperature 
which so often is the cause of the profound 
exhaustion . Instead of tubbing tepid packs 
possibly aided by gentle fanning should 
answer the purpose and will not unduly 
excite a nervous child. 

Virginia Medical Semi-Monthly, Jan. 10th, 
Principles of Surgery Lecture XLII— 
Surgical Tuberculasis (could)— Tuber- 
culosis ol the Peritoneum— Tuberculosis 
of Lymph Nodes — Tuberculosis ol Ten- 
don Sheaths.- By Dr. Stuart McGuire. 

A New Method of End to End Intesti- 
nal Anastomosis.— Dr. Samuel Lile says 
everything being sterile the abdomen is 
opened and the involved intestine brought 
out of the cavity. After locating that por- 
tion to be resected, clamp the center thereof 
with long jawed forceps. Now strip or milk 
the gut from the centrally placed forceps, 
both proximally and distally, and while the 
stripping fingers are in place, two inches 
beyond where incision is to be made, put 
on clamps. The indicated portion of gut is 
now removed with either knife or scissors. 
Make the incision exactly at right angles 
through the intestine to point of division. 
This is essential to avoid tension or pucker- 
ing when the ends are approximated. It is 
always well to leave an artery forceps near 
the end of both cut surfaces. In cases 
where the resected piece is only a few inches 
it is best not to take out any of the mesen- 
tery, but fold it on itself and stitch, care- 
fully avoiding all blood vessels possible. If 
the resection is long it will be necessary to 
remove a V-shaped piece of mesentery with 
scissors, taking care to preserve the artery 
supplying the end of the intestine, proxi- 
mally and distally, and ligate all bleeding 
points. With scissors or knife make a 
longitudinal incision exactly opposite to 
the mesenteric attachment in both ends of 
gut and approximately equal to the circum- 
ference of same. Mow bring the ends to- 
gether; evert so as to throw the two peri- 
toneal surfaces in contact, thus making a 
straight instead of a circular line and stitch 
them with through and through stitches. 
Now reinvert and sew with Chas. Mayo's 
modification of Counel's suture, the longi- 
tudinal incisions which have now become 
one straight cut. In order to prevent puck- 
ering sew the angles together first. Be care- 
ful not to tie sutures too tightly, thus avoid- 
ing constriction and possible sloughing. 
The through and through sutures may be 
either interrupted or continuous. It will be 
seen at once that the special features of this 

operation are that the sewing is in straight 
lines with surfaces well approximated, and 
easily seen and handled. After the bowel 
has been firrnly stitched cover the stitches 
in the circular wound with peritoneum by 
a row of Lambert stitches, for fear of possi- 
ble infection from the through and through 
sutures, they have been passed through the 
mucous coat of the bowels first (or from 
within out ) . A continuous stream of warm 
normal salt solution keeps the bowel expos- 
ed nearly normal. The bowel being wrap- 
ped in sterile towels. The bowel is now 
replaced in the cavity; the omentum care- 
fully straightened out and the abdomen 
closed in lavers. 

Richmond Journal of Practice, Dec, 1907 . 
Impressions of London Surgery.— Dr. 

J. R. Eastman says one is impressed by the 
cool, self-reliant indifference of London sur- 
geons to foreign notions of asepsis, and be- 
gins to wonder, in view of the admiral 
results achieved here, whether Americans 
are not absurd. And yet, however seriously 
one may doubt the wisdom of pinning abso- 
lute faith to asepsis, one cannot with confi- 
dence embrace the London idea so long as 
one sees the best London surgeons generally 
placing large drains in wounds which prior 
to operation were aseptic. It is difficult to 
free one's self of the suspicion that "there 
is a nigger in the woodpile." If one does 
not see it himself, the visitor will be assured 
daily by his hosts that the English, lacking 
faith in physical and chemical agents, use 
more soap and water and common sense 
than we do. And it must be confessed that 
from the housewife's standpoint London 
hospitals are almost without exception quite 
clean. They are macrosopically aseptic, if 
indeed the}' are not so microscopically in 
the relative sense in which we use this word. 
Moreover, the English surgeon is sensible. 
He does not poke his finger into sterile 
joints, even if glove covered. He practices 
Koenig's "knife and fork surgery" when- 
ever possible, and in such factors as these, 
if anywhere, the explanation of the appar- 
ent pardox is to be sought. It is more than 
possible that too great faith in the ability 
of antiseptics to produce asepsis may blind 
one as to the value of simple cleanliness as 
originally produced by soap, water and 
brush — and plenty of them. So long as the 
basin of antiseptic lotion is too conveni- 
ently near, the soft brush or soapy gauze 
mop, the use of which involves physical 
exertion, does not appear as it should to an 
indifferent nurse or assistant, species not 
yet extinct in the United States. Among 
many practices which strike the visitor as 
being of interest and importance are those 



of opening nearly all fractures for accurate 
coaptation, the slow thirsting out of vari- 
cose veins, the use of nitrate of silver, cat- 
gut and gauze, the use of sulphur in place 
of iodoform in tubercular abscesses and 
sinuses, early and almost immediate opera- 
tion in hair-lip and cleft palate, resection of 
the colon and short circuiting operations in 
chronic constipation, and Bland-Sutton's 
practice of removing all diseased gall- 
bladders, broadly speaking, upon the hypo- 
thesis that bile is purely excremeutitous and 
that therefore even a gall-bladder is like the 
appendix — practically useless. Finally one 
chronicles the impression that Loudon sur- 
geons are intrepid operators and scientific, 
notwithstanding their methods are stubborn 
and independent, verifying everything for 
themselves. They are notably and notori- 
ously cordial to their visitors. Their hearts 
like their incisions are big. 

unless it is borne out by that of others, but 
at the present time we must arrive at a con- 
clusion as to several phases of cancer by a 
comparison of experiences. May the day 
soon come when its etiology will be plain; 
then we may be able to attack the subject 
from a more truly scientific standpoint. 
The writer has seen three instances where 
there was some reason to suspect the disease 
to be due to contagion — a woman with can- 
cer of the breast who had had two sisters to 
die of cancer, although the ancestry was 
apparently free — another case where a 
mother died with a cancer of the uterus; 
then a son with cancer of the rectum, then 
the father with the same disease. 

The Louisville Monthly Journal of Medicine 
and Surgery, January, 1908. 

The Contagiousness of Cancer.— Dr. T. 

L. Butler believes that the evidence of auto- 
inoculation is so abundant that it seems 
scarcely to permit of any degree of doubt. 
As to the modus operandi of this contagion 
there is considerable difference of opinion. 
Whether it is required that a portion of the 
soil, as well as the cancer cell, be implanted, 
whether the cell alone is all-sufficient, or 
whether it is necessary that some special 
form of muco-organism be present, is yet to 
be determined. We have abundant proof 
that a small clump of epithelial cells when 
dropped on a granulating surface will pro- 
duce themselves if the soil is in proper con- 
dition, in the Reverdin method of skin 
grafting. Although they apparently dis- 
appear, enough find lodgement to begin an 
active cell proliferation. That an epithelial 
cell has peculiar powers of reproducing it- 
self after a long time under adverse circum- 
stances is shown by the Lusk method of 
skin-grafting. This form is emphasized in 
the cancer cell — as Adami stales, it gives up 
the habit of growth and reproduction. There 
can hardly be a doubt at the present day 
that carcinoma is primarily a local disease. 
It so and there is such a thing as auto- 
inoculation it is logical to suppose that if 
proper conditions prevail there is such a 
thing as cancer being transmitted from one 
individual to another. Theoretically the 
factors requisite for this to take place are 
such that it renders it an extremely improb- 
able occurrence, yet it is a clinical fact 
taken from reports of men of undoubted 
integrity that its occurrence is not so fre- 
quent as one would suppose. The limited 
experience of one observer proves very little 

New Orleans Medical and Surgical Journal 
Jan., 1907. 
Removal of Hemorrhoids by the Angio- 
trlbe Method.— Dr. S. P. Delaup gives the 
technique of angiotribe operation as per- 
sormed under spinal analgesia by Dr. 
Chassaignac and himself as follows: The 
patient having been previously prepared 
and the spinal injection made, is placed in 
Sim's position. The sphincter is gradually 
and thoroughly divulsed by making pressure 
with the thumb or fidgers first in one direc- 
tion and then in another or with the Cooks 
speculum. The hemorrhoids are then ex- 
posed by everting the anus, and the number, 
size and location noted. The next step is 
also common to all methods, determining 
how many of the hemorrhoidal masses and 
what ones should be removed. This is best 
effected by firmly grasping each tumor with 
hemorrhoidal forceps and making traction 
so as to put the parts at its base well upon 
the stretch. The angiotribe — Thuminn — is 
now adjusted; it will not only enclose the 
whole of the pile but will reach up to the 
normal mucous membrane above, so that 
its vascular supply is wholly controlled. 
Practically the situation is the same as 
when the surgeon applies the clamp for the 
clamp and cautery operation. The portion 
of the pile that protrudes beyond the angio- 
tribe is now cut flush with the angiotribe 
knife or scissors just the same as in the 
clamp and cautery operation. The angio- 
tribe is allowed to remain for four or five 
minutes. Pending the compression the ex- 
cised tumor flush with the angiotribe may 
be touched with a pleget of cotton saturated 
with pure carbolic acid. The angiotribe is 
then removed and reapplied as often as 
necessary; the most aggravated case never 
requiring more than four applications. 
When the procedure has been completed 
there results a well and satisfactorily secur- 
ed wound, the wound surfaces are in appo- 
sition, the perianal skin redundances have 
been in great part removed, and the traces 



of the operation then present to inspection 
two, three or more small compressed wound 
lines radiating from the anus. These are 
gently returned within the sphincter and 
held in a firm wedge- shaped gauze compress 
applied over the anus and firmly secured in 
place by a well adjusted T bandage. The 
patient is then placed in bed. The rectum 
should not be irrigated nor any instrument 
introduced after operation has been com- 
pleted from fear of tearing open the com- 
pressed wound. If the compression has 
been thorough and if no dressings, packing 
or tubing of any kind are placed in the rec- 
tum there will be comparatively little if any 
after pain. 

Maryland Medical Journal, January, 190S . 
Tumors of Lateral Aberrant Typhoid 
Tissue. — Dr. A. McGlaunau says that ac- 
cording to the position the masses of aber- 
rant typhoid tissue are classified as median 
or lateral. Both groups are divided into 
superior and inferior according to their rela- 
tion to the line of the hyoid bone. The 
median are those occurring in the median 
line of the neck in the line of the thyroid 
glassus duct. These are developed from 
islands of epithelium cutoff from the isthmus 
in its downward course during the growth 
of the neck. The lateral are those occurring 
in the line of the great vessels of the neck 
and the other branches from the arch of the 
aorta. During the development of the neck 
and shoulder girdle pressure of the great 
vessels and developing muscles on the tis- 
sues of the lower clefts causes separation of 
islands of epithelium that later form the 
lateral aberrant thyroid masses. Schrager 
suggests that latent aberrant thyroids may 
occasionally originate either from the normal 
or supernumerary parathyroids. These sep- 
arated islands grow in proportion to the 
normal evolution of the thyroid, and unless 
they represent a considerable part of the 
total thyroid material the lateral aberrant 
masses will give no clinical symptoms. 
Embryonic separation may strew the entire 
area with minute particles of thyroid that 
are without clinical significance or symp- 
toms. However, these aberrant masses are 
subject to all the pathological changes of 
the normally placed thyroids and may have 
any hypertrophy or tumor formation that 
affects the glands. The common position 
of the lateral aberrant thyroids is that of 
the lymphatic glands of the neck and axilla. 
Adenoma may develop simultaneously in 
the thyroid in normal position and in the 
aberrant masses. When these tumors are 
removed those found in the aberrant tissue 
may be mistaken for glandular metastasis 
from adenoma of the normally placed thy- 
roid. Metastatic growth is considered one 

of the cardinal symptoms of malignancy 
and therefore it is unreasonable to attribute 
the same property to a benign tumor. 

An important point apparently overlooked 
by all operators is the condition of the lym- 
phatic glands in these cases. Normal lym- 
phatic glands would prove absence of 
metastastis. No one has mentioned the 
lymphoid tissue in describing the masses. 
It is conceivable that the metastatic deposit 
may entirely replace the lymphoid cells so 
that the lymph gland is converted into a 
nodule of tumor cells, but such complete 
replacement is practically unknown. Erd- 
hart has shown that the relation of adenoma 
of the thyroid to adeno-carcinoma is very 
close, and that in the transition from one 
type of tumor to the other the histological 
change is slight and easily overlooked. 

The Southern Practitioner, January, 1908. 

History ol Syphilis.— Dr. J. M. King be- 
lieves that local venereal disease of con- 
tagious character and formidable symptoms 
was known to all the ancients of whom we 
have any record. Among the ancient writ- 
ings of the Greeks, Romans, and Arabians, 
the following troubles were described: 
Eating sores of the prepuce and glands; 
puriform discharges from the urethra; can- 
cer and gangrene of the penis; enlargement 
of the inguinal glands; tumif action of the 
testicles; abscesses, pustules, and gangrene 
of the vagina. It is cited in Thucydes that 
the raucous voice, fiat nose, ulcerations of 
the legs and lesions on other parts were the 
results of venereal disease. Venereal disease 
offered no grounds for divorce among the 
Greeks and Spartans. If syphilis existed 
among the ancients it is probable that it 
had not attained the virulent and formid- 
able condition of later date. Although the 
ancients seemed to recognize that systemic 
consequences followed debauchery they 
confused physiological functions with dis- 
eased conditions. Menstruation was con- 
fused with disease of the genital organs. 
They believed that the menstrual discharge 
was a combination of the most obnoxious 
impurities of the body, and intercourse with 
a woman who had lately menstruated was 
not permitted under the conviction that it 
was a source of leprosy and a number of 
other diseases, either of the skin or genital 
organs. They held at that time another 
very peculiar notion as to the cause of geni- 
tal lesions. It was believed that by absti- 
nence from intercourse the semen became 
acrid and poisonous, and finally affected 
the whole economy. They also believed 
that genital and anal disturbances were due 
to the liver. John Alummer attributed the 
cause of syphilis to a morbid condition of 
the humours which taking origin in the 



liver, is propagated to the genital organs. 
James Catameo believed it to be caused by 
ageneral conception of the blood produced 
by poison of the menses and though he be- 
gan to think that disease of the genital 
organs was caused by intercourse still he 
was of the opinion that these persons were 
especially predisposed and that they had a 
dry and a warm liver or a humid and cold 
brain. Even in 1635 John Johnson placed 
the seat of syphilis in the liver. When we 
consider the existence of such confusion on 
the subject of venereal diseases in the seven- 
teenth century we may despair of any type 
of definite aid or light on the subject from 
the ancients. Among the Hebrews there is 
no reference in their sacred writings in the 
commentary of Josephus in the Talmudical 
books which verifies the existence of syphilis 
although in Egypt today the natives desig- 
nate the disease by the expression "marred 
Ayout" which means the disease of Job. 

Nashville Journal of Medicine and Sugery, 
January, 1908. 

Arthritis Deformans.— Dr. J. V. Shoe- 
maker gives the following under the section 
on treatment: The treatment should be 
hygienic, dietetic, electrical and medicinal. 
The hygienic treatment should consist of 
plenty of fresh air, sunlight, bathing and 
massage. The patient should receive a 
warm bath daily — if possible a vapor or 
Turkish bath twice a week. If the patient 
is confined to bed a warm salt water or alco- 
hol sponge bath ma}' be given. The various 
baths are invigorating and stimulating to 
the skin. Massage should be employed to 
better influence the circulation to the affect- 
ed parts, thus increasing the elimination, 
tones up and restores the affected muscles 
and ligaments to their normal condition. 
Passive motion breaks up the adhesions 
and creates an inflammation which leads to 
absorption of the adhesive products. The 
diet should consist of nutritious, well-cooked 
vegetables, and especially those containing 
comparatively large amounts of sulphur 
and iron in combination such as spinach, 
corn, lettuce, turnips, cauliflower, aspara- 
gus, onions, mustard and horse radish. 
Cooked beans, peas, barley, prunes, apples 
and pears contain much nutrition for the 
nervous system and are a good substitute 
for the nitrogenous and fatty foods. Further- 
more they do not disturb the digestive organs 
as do the meats and other nitrogenous foods. 
Stewed fruits should be given for the salts 
and acids they contain. They are appetiz- 
ing and have a laxative effect. A proper 
and suitable diet as outlined is all important 
in the successful treatment of this disease. 
We should aim to build up the digestive 

organs, make the nutritive forces more 
active, change the state and character of 
the blood, and thus restore the nervous sys- 
tem to the normal condition, or as near so 
as possible. Electricity in the form of frac- 
tional or static, the galvanic and the faradic 
alternating, both for the central as well as 
the local effect is a valuable adjuvant in the 
treatment. The application of either of the 
currents named certainly tones up the cen- 
tral nervous system and gives additional 
vigor to all the glands, both within and 
without the body. It stimulates the dorm- 
ant molicules of every tissue in the body 
and adds to the vigor of the digestive 
organs. It assists absorption and elimina- 
tion of all the morbific material in the 
system. Electricity has equally as good an 
action locally as it possesses in this class 
of cases constitutionally. It awakens the 
activity of the molecules of the affected 
joints, stimulates the dormant circulation 
and promotes the absorption of the poured 
out products. Electricity likewise stimu- 
lates the inactive muscles and ligaments of 
the diseased joints far deeper and better 
than any other method that we may employ, 
not even accepting massage. 

Virginia Medical Semi- Monthly, Jan. 24th, 
Strangulated Inguinal Hernia in In- 
fants—with Report of a Case.— Dr. J. E. 
Cannaday says the treatment in most cases 
is undoubtedly surgical so long as the pati- 
ent is not moribund. When the patient is 
seen early after the symptoms of strangula- 
tion have made their appearance, and when 
the onset has not been acute, taxis should 
be resorted to, and in event of failure the 
hernia sac should be opened at once. Taxis 
is thought by some to be more especially 
indicated in the very young, who are hard 
to keep clean, and in the aged and infirm 
who do not bear operation well. Taxis 
may waste valuable time and may bring 
about the reduction of hernia en bloc or 
bowel that has lost its vitality. Violent 
manipulations may cause tearing of the 
intestine. Before resorting to taxis the 
stomach and lower bowel should be irri- 
gated and emptied, the urine should be 
drawn, muscular relaxation obtained by 
appropriate posturing and the use of an 
anesthetic, the hernia should be elevated so 
as to be the highest part of the body. The 
fluid contained in the sac when opened is 
an excellent indicator of the condition of 
the intestine. If the fluid is ill smelling or 
contains flakes of lymph the bowel is very 
likely to be in bad condition. In attempt- 
ing to make a decision whether a piece of 
gut is viable or not, the sense of touch may 
give more information than that of sight. 



The lifeless gut is flaccid and has the feel 
of moist blotting paper. Gray-brown spots 
are indicative of gangrene. Resection and 
even the formation of an artificial anus will 
often have to be resorted to. When there 
has been much infection the radical opera- 
tion should be omitted and the wound pack- 
ed with gauze. In case of doubt, sutures 
can be placed and left loose to be tied later. 
When the radical operation is resorted to it 
is usually best to make use of the simple 
and time saving methods. The author does 
not believe that the transplantation of the 
cord has any particular merit to commend 
it. Connell and Ferguson are quite certain 
that it predisposes to epididymitis or other 
inflammatory lesions. Operation infection 
should be very rare when a careful rubber- 
glove technique is followed. After ligating 
the neck of the sac the author often carries 
the ends of the suture upward between the 
parietal peritoneum and rectus muscle and 
secure the neck of the sac in a higher posi- 
tion so as to obliterate the former funnel- 
like depression existing at the point of oc- 
currence of hernia, after dealing with the 
sac the hernial opening is closed by the 
introduction of sutures of thirty day chromic 
catgut. The idea suggested by Czerney 
and later elaborated by Ochsner that if the 
ring is denuded of its lining before being 
closed union will be assured and recurrences 
rare, should be one of the basic principles 
of surgery of this part of the body. The 
cord is not moved from its normal position 
and the superficial is sutured over it with a 
running suture of plain catgut. The edges 
of the skin wound are approximated with 
the usual suture of silk or linen thread. 

Texas Medical Journal, Dec., 1907. 
Wright's Principle of Vaccine Therapy. 

-By Dr. H. N. Graves. 

The Southern Clinic, January, 1908. 

The Future Science of Medicine.— By Dr. 

J. M. Taylor. 

Book Notices. 

Surgery: Its Principles and Practice. In 
five volumes. By 66 eminent surgeons. 
Edited by W. W. Keen, M. D., LL.D., 
Hon. F. R. C. S., England and Edin- 
burg, Emeritus Professor of the Princi- 
ples of Surgery and of Clinical Surgery, 
Jefferson Medical College, Philadelphia. 
Volume III. Octavo of 1132 pages, with 
562 text-illustrations and 10 colored 
plates. Philadelphia and Loudon: W. 
B. Saunders Company, 1908. Per volume: 
Cloth, $7.0(1 net; Half Morocco, 3S.00 

The third volume of Keen's Surgery is as 
beautiful a work as one see. The illustra- 
tions are elaborate, and most instructive. 
A glance at the list of contributors to this 
volume, including names from both America 
and Europe surgeons whose fame is limit- 
ed only by the circumference of the globe — 
is guarantee of the great excellence of the 
work now appearing under the editorship 
of Dr. W. W. Keen,' of Philadelphia. 

The subjects treated in volume III and 
the authors are: Surgery of the Head, by 
Harvey Cushing, M. D.; Surgery of the 
Neck, by E. W. Andrews, M. D. ; Diseases 
of the Thyroid, by A. Kocher, M. D.; The 
Nose and Accessory Sinuses, by Harmon 
Smith, M. D.; Surgery of the Larynx and 
Trachea, and of the Thorax, by Geo. E. 
Brewer, M. D.; Surgery of the Breast, by J. 
M. T. Finney, M. D. ; Surgery of the Mouth, 
Teeth, and Jaws, by Edmund Owen, M.B., 
F. R. C. S.; Surgery of the Tongue, by J. 
C. DaCosta, M. D.; Technic of Abdominal 
Surgery, Surgery of the Abdominal Wall, 
and of the Peritoneum and the Retroperi- 
toneal Space, by Jno. C. Munroe, M. D.; 
Surgery of the Oesophagus, by George 
Gottsteiu, M. D.; Surgery of the Stomach, 
by Mayo Robson, F. R. C. S.; Surgery of 
the Liver, Gall-bladder and Biliary Ducts, 
by Drs. W. J. and C. H. Mayo; Surgery of 
the Pancreas and Spleen, by B. G. A. 
Moyinhan, F. R. C. S. 

Thus each chapter is an original and 
complete monograph by an authority of 
recognized eminence. The very latest work 
in the field of surgery and destined to be- 
come the standard 

Diseases-of the Heart. By Prof. Th. von 
Jurgeusen, of Tubingen; Prof. Dr. L. 
Krehl, of Griefswald; and Prof. Dr. L. 
von Schrotter, of Vienna. Edited, with 
additions, by George Dock, M. D., Pro- 
fessor of Medicine, University of Michi- 
gan, Ann Arbor. Octavo of 848 pages, 
illustrated. Philadelphia and London: 
W. B. Saunders Company, 1908. Cloth, 
$5.00 net; Half Moroceo, $6.00 net. 
This adds yet another volume to the mag- 
nificent series of English translations of 
Nothnagel's Encyclopedia of Practical 
Medicine, appearing under the able editor- 
ial supervision of Dr. Alfred Stengel, of the 
University of Pennsylvania. This volume, 
the twelfth of the series, contains the writ- 
ings on the Diseases of the Heart by Pro- 
fessors von Jurgeusen, of Tubingen, von 
Schrotter, of Vienna, and Krehl, of Griefs- 
wald. The German edition has been edited 
with additions by Dr. Geo. Dock, of the 
University of Michigan, and the work is 
now even superior to ihe original because 
it contains not only the work of the German 
authors, but has been brought thoroughly 



down to date by annotation and additions 
by one of America's foremost medical 
writers. The many and important contri- 
butions in Germany to our knowledge of 
the normal and pathologic anatomy of the 
heart, the physiology of the heart and cir- 
culation, methods of diagnosis, and the 
pharmacology of cardiac remedial agents, 
medicinal and non-medicinal, renders a 
work of this kind especially valuable since 
it brings to the great mass of English speak- 
ing physicians a reference book of the very 
highest value. The text has been made 
very clear and as concise as possible. 
Medicinal remedies are given in conform- 
ance with the U. S. Pharmacopoeia. 

The Doctor's library is in no sense com- 
plete without a set of Nothnagel's Works. 

The Pyonex: Its Theory and Practice. By 

W. B. Rule, M. R. C. S., L. R. C P. 

London: John Bale, Sous & Dauielsson, 

Ltd. 1907. 

This book contains descriptions of a 
special method of treatment applicable — 
according to the author of the book — to 
everything from Indigestion to Locomotor 
Ataxia and Spinal Curvature. Pyonex is 
derived from a combination of two Greek 
words which convey the signification of 
pus expeller. The author claims that by 
the use of the instrument, to which the term 
is likewise applied, the causes of the disease 
are expelled or eliminated from the human 
body. One gets the impression in attempt- 
ing to grasp the rationale of these methods 
that the whole thing is quackery-pure bosh. 
The idea of puncturing the skin, introduc- 
ing infective micro-organisms which pro 
duce a purulent inflammation (for this is 
really the result of the operation) and then 
saying that the pus formed is due to the 
elimination of the causative agents of the 
disease seems to the intelligent reader a relic 
of mediaeval days. The book should be 
consigned to the trash heap. 

Eleventh Biennial Report of the North Caro- 
lina Board of Health, 1905-1906. Dr. R. 
II. Lewis, Sect'y., Raleigh, N. C. 

Practical Fever Nursing. — By Edward C. 

Register, M. D., professor of the prac- 
tice of medicine in the North Carolina 
Medical College; chief physician to St. 
Peter's Hospital, editor of the Charlotte 
Medical Journal. Illustrated; cloth, pp. 
352. Price 52.20 net. W. B. Saunders 
Company. Philadelphia and London, 

The author's object in writing this book 
in the preface to be "to present to nurses a 
working text-book that will completely 
cover the field of practical fever nursing." 
This he has done well, and in such a man- 

ner that we feel sure nurses will find it of 
great value in this practical branch of their 
work. In the first third of the book the 
author presents under the heading "Gen- 
eral Considerations" such topics as the 
sickroom, the pulse, the respiration, charts, 
clinical thermometer, hypodermic injec- 
tions, hyperdomoclysis, catherization, bed- 
pan, the preparation of the more common 
articles of diet in fever cases, antipyretics, 
the cause and contagion of fever, symptoms 
common to fevers, symptoms referable to 
special organs. Next he treats of the 
"Prevention of Fevers," describing the 
various methods of chemic and physical 
prophylaxis, disinfection and sterilization, 
The remainder of the work is devoted to the 
consideration of the following fevers: 
Typhoid, malaria, pneumonia, pulmonary 
tuberculosis, influenza, diphtheria, rheuma- 
tism, cerebro-spinal meningitis, puerperal 
fever, yellow fever, dengue, relapsing fever, 
bubonic plague, small-pox, vaccination, 
chicken-pox, typhus fever, scarlet fever, 
measles and German measles. Each dis- 
ease is taken up separately and its cause, 
symptoms, varieties, pathology, diagnosis, 
complications, prophylaxis, prognosis and 
treatment given in such a non-technical 
manner that the practical lesson is evident 
at once. A nurse cannot act intelligently 
in the care of fever patients unless she 
knows something of the disease and its 
treatment, the various pathologic processes 
involved, complications, etc.; in other 
words unless she be something more than 
a mere automatum. To select this knowl- 
edge and to impart it to nurses without car- 
rying them into the domain of medicine is 
one of the greatest essentials of book-mak- 
ing for the instruction of nurses. This has 
been accomplished in the work presented 
under the above title. It is well arranged, 
the illustrations are clear, the text is full, 
but not burdened, the workmanship is pleas- 
ing, and the whole book worthy of recom- 
mendation. — Trained Nurse, Oct. 1907, 
N. Y. 

f\ Or.iat Opportunity for Sufferers from 
Nervous Troubles. 

The vast number of people who have read 
and been benefited by Dr. George Lincoln 
Walton's notable series of papers on "Worry 
and Allied Mental States," in Lippincott's 
Magazine, will be quick to seize upon the 
March issue, which contains the conculd- 
ing article — "Home Treatment." Each of 
the previous papers contained advice and 
suggestions for relieving sufferers from those 
annoying minor metal ailments with which 
so many of the sanest of us are afflicted, but 
this final essay goes more into detail, and 
those who follow the author's instructions 



are likely to avoid paying many a good- 
sized doctor's bill. For the benefit of peo- 
ple who have not read the other papers, the 
entire subject is reviewed in brief. As Dr. 
Walton is one of the most famous neurolo- 
gists of the day, this is a splendid oppor- 
tunity for all who are afflicted with sleep- 
lessness, hypochondria, the worrying habit, 
and similar derangements, to profit by the 
advice of a skilled specialist, without pay- 
ing the specialist's usual fat fee. 

Abstracts of the Leading articles 
of the month. 

The Heart Rhythm. - Gossage ( British 
Medical Journal) states that there are two 
opposing theories as to the origin of the 
automatic power of the heart to beat rhythm- 
ically, both of which recognize that the 
automatic power of the heart lies in itself, 
and is quite apart from the central nervous 
system or the circulation of the blood. These 
are the so-called neurogenic and myogenic 
theories, implying that the origin of the im- 
pulse lies in the nervous and muscular ele- 
ments respectively. The writer thinks that 
the complete myogenic theory has the more 
weighty evidence in its favor and should be 
accepted until stronger arguments are 
brought against it. It is not incompatible 
with any of the known phenomena of the 
heart beat, while it affords the best explana- 
tion of many of them. It is certain that the 
muscle fibres possess the powers of con- 
tractility, excitability, conductivity, and 
tonicity, and it is probable that these are 
exercised during the normal beat of the 
heart without the intervention of the nerv- 
ous tissue. It is also certain that all the 
muscle fibres are not capable of building up 
a stimulus for themselves, but there is evi- 
dence to show that certain fibres of peculiar 
structure possess this property. While cer- 
tain facts seem to find their readiest explana- 
tion in the neurogenic theory, especially the 
response of the quiescent heart to the stimu- 
lation of the accelerator nerve, there are 
others pointing as strongly to the hypothesis 
that the heart beat is purely muscular. This 
conception does not preclude the possibility 
of the beat being influenced by outside nerv- 
ous impulses. This would give a sufficient 
explanation of the large nerve supply of the 
heart. Attributing the rhythmic power of 
contraction to the muscle is, of course, only 
a very partial explanation of the cardiac 
beat, the cause of which lies deeper in 
physico-chemical changes in the cells. 

Locomotor Ataxia.— Dent (British Medi- 
cal Journal) holds that locomotor ataxia is 

essentially a chronic and progressive dis- 
ease, and that from a strictly curative point 
of view little can be expected. The course 
is usually very long — twenty or thirty years. 
Our aim, therefore, should be chiefly to re- 
lieve the symptoms and to arrest or retard 
the degenerative process as far as possible. 
Syphilis is responsible for most of the cases. 
Fatigue, excesses, cold, trauma, overstrain, 
intoxication, etc., are considered to be ex- 
citing causes. If syphilis be treated early 
and thoroughly, the probability of tabes is 
only lessened, not removed. The earlier 
the diagnosis, the better the outlook. Cases 
showing dyspepsia, neuralgia, burning sen- 
sations and numbness in the hands or feet, 
eye and laryngeal symptoms should always 
be carefully investigated. A valuable aid 
in early diagnosis is examination of the 
cerebrospinal fluid; if there is not excess of 
lymphocytes present, locomotor ataxia (and 
also general paralysis) can confidently be 
excluded. The cases may never advance 
beyond the preliminary or preataxic stage. 
Retention and incontinence of urine with 
cystitis, etc., are common symptoms. Salol 
and urotropiu here give excellent results, 
and it may also be necessary to wash out 
the bladder. Dyspnoea or laryngeal crises 
are, as a rule, not serious and may be re- 
lieved by a few whiffs of aniyl nitrite or 
chloroform. Perforating ulcers may form 
on the foot, and are to be treated by pro- 
longed rest in bed and antiseptics. Frac- 
tures of the bones are caused easily, and 
unite quickly with a great amount of callus, 
the condition being akin to the arthropathic 
changes seen in the joints where there is 
rapid effusion and abnormal movement 
(Charcot's joints), the knee being the joint 
most commonly affected. Frenkel's exer- 
cises are the best form of treatment for the 
ataxia, and even the worst cases show im- 
provement. They should be carried out 
under the eye of the doctor .and be perse- 
vered with for not less than a month. In 
certain cases the x-rays applied daily for 
five minutes to the dorsal region of the 
spinal column give good results. Baths in 
general aid the circulation and are refresh- 
ing and comforting. Benefit has been noted 
from the suspension treatment, but it is 
probably due to suggestion. Both galvanic 
and faradic currents have been used, but 
without any great result. Cold and damp 
climates aggravate the pains. Potassium 
iodide and mercury are largely given, but 
have little influence. Silver nitrate in one 
quarter grain doses often relieves and less- 
ens the pains and does permanent good. 
Aluminium chloride, gold chloride, zinc 
phosphate, and arsenic certainly help in 
some cases. Strychnine is constantly em- 
ployed for its tonic effect. Phenacetine and 



antipyrine are used for the relief of the pains 
and morphine should be postponed as long 
as possible. Testicular juice, spinal cord, 
brain substance, and spermin have been 
tried, but with very unsatisfactory results. 
Tabetic patients should not marry. 

The Surgical Treatment of Cerebro- 
spinal Meningitis.— Radmann (Neurol- 
gisches Centralblatt) says the operations 
hitherto performed upon patients having 
cerebrospinal meningitis, such as lumbar 
puncture, drainage through a canula after 
lumbar puncture, division of the atlanto- 
occipital ligament, punctures of the lateral 
ventricles with and without flushing — failed 
to influence the course of the disease. Neither 
is radical success from surgical treatment to 
be expected, since, on the one hand, the 
disease is not a local affection, such as the 
ordinary forms of purulent meningitis, but 
a general infection from the outset and dur- 
ing its entire course, and on the other hand, 
it is altogether doubtful whether cerebro- 
spinal suppurations can be cured by surgi- 
cal intervention, like ordinary suppurations. 
The meningococcus has an essentially dif- 
ferent effect upon human tissue, as com- 
pared to the other pus-producers. The sub- 
cutaneous injection of their own cerebro- 
spinal fluid into patients suffering from 
cerebrospinal meningitis, does not give rise 
to a reaction of any kind, the meningococcus 
producing neither single local foci nor ab- 
scesses, but attacking preferably the pia. 
From the symptomatic point of view, also, 
surgical interference in the early stages is 
of little value. Lumbar puncture is follow- 
ed by Temporary relief only in certain indi- 
vidual cases. The systematic employment 
of this procedure for therapeutic purposes is 
not advisable. The increase in cerebral 
pressure in the early stages does not require 
intervention. In the late stages, however, 
when the major part of the severe manifes- 
tations is due to the purely mechanical ef- 
fect of the increased fluid, the artificial 
establishment of permanent drainage seems 
to be of clinical benefit. Since the cerebrum 
is not permanently relieved by lumbar punc- 
ture and simple ventricular puncture, the 
author in two cases tamponed the lateral 
ventricles, with considerable, though transi- 
tory, improvement of the symptoms. One 
of these patients survived for ten, the other 
for seventeen days after the operation. For 
the better control of the drainage, and fo r 
the avoidance of secondary infection during 
the after-treatment, it is advisable to intro- 
duce into both ventricles a silver wire fixture 
with threads which can be successively with- 
drawn, thus removing obstruction to the 

The Mechanism oi the Reflexes.— Van 

Gehuchten (Neurolgisches Centralblatt.) 
believes that reflex movements may be di- 
vided into tendon reflexes and cutaneous 
reflexes. The former are invariably caused 
by the movement of a single muscle; the 
latter are mono-muscular as far as clinical 
skin reflexes are concerned, whereas the 
so-called physiological skin reflexes are 
poly muscular. All these reflexes have their 
immediate centre in the gray substance of 
the nervous system; but the tendon reflexes, 
and the clinical skin reflexes, can originate 
only by the assistance of the white substance. 
In order to learn the particular part allotted 
to the white and the gray substance, respec- 
tively, it is necessary to study the anatomy 
and physiology of the spinal cord. Physi- 
ologically considered, the cord consists of 
two organs: an autonomic organ, the reflex 
centre; and an "intermediary" organ, rep- 
resented by the nerve-fibres. After the 
removal of the ascending and descending 
nerve fibres from the spinal cord, those parts 
would be left behind which by themselves 
constitute an independent organ. A spinal 
cord composed in this manner is capable of 
functionating, as has been demonstrated by 
observations upon patients suffering from a 
complete transverse lesion in the cervical 
portion. These patients present paraplegia 
with disappearance of the tendon reflexes, 
and the skin reflexes of the clinician. How- 
ever, stimulation of the skin in one of the 
lower extremities gives rise to an immediate 
movement. This reflex movement is abso- 
lute y involuntary and takes place without 
any consciousness. Even the spino-spinal 
fibres (van Gehuchten) are not necessary 
for the fnnctiou of this part of the spinal 
cord as a separate organ, as shown by obser- 
vations on complete transverse lesions in the 
thoracic or lumbar segment. The spinal 
cord may thus be imagined to be made up 
of as many segments as there are peripheral 
nerves. Each segment accordingly is the 
seat of a special reflex. This reflex appa- 
ratus is composed of two neurons, one centri- 
petal and one centrifugal. Thus the spinal 
cord ultimately consists of a large number 
of units of gray substance, which communi- 
cate with peripheral nerves. Each one of 
these units may be interpreted as a primi- 
tive medullary ganglion. By successively 
adding the fibres of the white substance, we 
obtain the structure of the spinal cord, such 
as it actually is. At the same time it will 
be seen what changes in the function are 
brought about by this addition. These 
primitive ganglia are connected with each 
other by nerve fibres (spino-spinal fibres), 
which results also in a communication be- 
tween a centripetal fibre and many centri- 
fugal fibres. Hence, the stimulation of one 



centrifugal fibre may be transferred to a 
large nuinber of motor cells. A polymus- 
cular movement results, which is at the 
same time co-ordinated. The spinal cord 
thus also has an influence upon the co-ordi- 
nation of movements. 

Higher nervous centres enter into com- 
munication with this complex of ganglion 
cells and fibres, and the bulbar centres com- 
municate with the individual centres located 
in the brain, especially those which are con- 
nected with the optic nerve and the cortical 
centres. The fibres passing from the two 
above-mentioned groups to the medullary 
ganglia, permit the origin of the tendon re- 
flexes which can be provoked by tapping 
upon any voluntary tendon. The fibres 
coming from the cortical centres exercise a 
sort of brake-like action, diminishing the 
intensity of the skin and tendon reflexes, 
and at the same time giving rise to a new 
reflex : the cutaneous reflexes of the clinician. 
Thus, three kinds of reflexes originate from 
the spinal cord: (1) The skin reflexes of 
the physiologist, which are exclusively of 
medullary origin. (2) The tendon reflexes, 
which have their centre in the spinal cord, 
but at the same time require the assistance 
of other fibres. (3) The cutaneous reflexes 
of the clinician, likewise from reflex centres 
in the spinal cord, but becoming active onlv 
through descending fibres which originate 
from cortical centres. This division is of 
great clinical importance. An old physi- 
ological law teaches that the higher nervous 
centres act upon the lower ones after the 
fashion of a brake. This law is not appli- 
cable to man , although this brake-like action 
as such does not exist, but it is exerted ex- 
clusively upon the true spinal cord reflexes 
(the physiological skin reflexes). This ex- 
plains at the same time why these reflexes 
are the only ones to be increased in com- 
plete transverse lesions in the cervical por- 
tion. A study of the reflex movements 
shows the great importance of the sensory 
nerve fibres, and illustrates the difference 
existing between the number of centripetal 
fibres — (1,300,000 in the spinal cord — and 
of centrifugal fibres — (400,000 in the spinal 
cord). The importance of these sensory 
nerve fibres is such that it may be stated 
that without them, life itself would be im- 
possible. Thus, instead of saying, with 
the philosopher: "I think, accordingly I 
am," the anatomist has a better right to 
assert: "I am, I live; hence, I am stimu- 

Diabetic Neuritis.— Pavy (Lancet) points 
out that an altered vascular state emanates 
from nerve lesions through the influence 
exerted on the functional capacity of the 
vessels. Nutritive operations are liable to 

be influenced secondarily. He refers to the 
trophic conditioa arising from diabetic neu- 
ritis, and says that trophic lesions may occur 
in connection with diabetes as a primary 
result of the effect of the sugar abnormally 
passing through the system. Diabetic neu- 
ritis is a very variable affection with respect 
to location, but its development exhibits a 
symmetrical character. The lower limbs 
suffer more frequently than the upper. 
Sometimes the neuritis is localized in a 
single nerve. Looking at the circumstances 
existing, it is not surprising that we should 
have a protean class of symptoms to deal 
with in diabetic neuritis. Some few cases 
had fallen under his observation in which 
anginal symptoms had existed in connec- 
tion with the diabetes, probably arising 
from involvement of the pneumogastric 
nerve. A toxic factor operates in peripheral 
neuritis, and in books it is stated that a 
toxic agent stands as an operative factor in 
diabetic neuritis as well. In Ross and Bury's 
work on "Peripheral Neuritis" it is stated 
that certain facts seem to indicate that the 
neuritis is not due to an excess of sugar in 
the blood. His experience was diametri- 
cally opposed to this allegation acquitting 
the sugar. Neuritis does not occur where 
the sugar is kept down by treatment. Con- 
joined with the dietetic and codeina or 
opium treatment for the diabetes, he has 
obtained beneficial effects from the admin- 
istration of 5 grs. of iodide of potassium 
and 10 grs. of bromide of ammonium thrice 
daily. If there is much superficial pain he 
applies cautiously linimentum aconiti. 

On Black Urine. -Garrod (The Practi- 
tioner) gives a brief account of the import- 
ance which has been attached to this phe- 
nomenon from ancient times, citing cases 
in which the condition existed in healthy 
persons. He then gives a list of diseases 
which may produce black or dark urine. 
The first disease discussed is jaundice. It 
is not common for urines containing bile 
pigment to approach to blackness, but when 
there is a large amount of biliverdin, to- 
gether with bilirubin and other varieties of 
bile pigment, they may appear black. Black 
urines of this kind are more common in 
cases of long-standing jaundice in which 
the skin has become a dirty greenish hue. 
The writer thinks that it is probable that 
many of the black urines described in the 
earlier literature owed their blackness to the 
admixture of blood or of haemoglobin. The 
term "black water fever," the writer states, 
bears witness to the character of the urine 
which may result from the presence of 
haemoglobin. In cases of poisoning by cer- 
tain drugs the urine may appear opaque 
and practically black . In hsematoporphyri- 


nuria the color of the urine usually resem- ological action and correct application, and 
bles that of port wine, but various degrees other standard remedies; and the remedies 
of tint are met with. True melanuria assoc- and methods used by every school up to 
iated with melanotic sarcoma is a rare con- this time considered quackery, whether 
dition. In melanuria the urine has usually homeopath, eclectic, osteopath, Christian 
a normal color when passed, although it science or what not — would of necessity 
may have a brown tint, but after being ex- show what is truth upon which our fathers 
posed to air it quickly becomes brown, and founded their faith, and in which we have 
finally as black as ink. In alkaptonuria as been raised. We are asked to cut loose 
in melanuria the urine is of normal color from our moorings and drift anywhere, 
when fresh but darkens on standing. In upon an unknown sea; nothing is offered in 
the condition of ochronosis — a term given exchange, except, perhaps, better pav. He 
to a blackening of the cartilages and of believes these views have been born as the 
some other tissues — the urine has been ob- result of unpardonable ignorance on the 
served in a few cases to blacken on stand- part of many of the profession of Materia 
ing. Medica and Therapeutics. Because of the 

Any morbid process which leads to abund- inroads made by the manufacture and sale 
ant excretion of indican may give rise to of proprietary preparations, the doctor lets 
dark urine — intestinal obstruction from any the drummer do his thinking and prescrib- 
cause, excessive bacterial activity in the ing for him; he fails to get results and loses 
intestine, or putrefactive changes in collec- faith, and becomes a fit subject to be blown 
tions of pus. Indicanuria is not nearly so about by any wind of doctrine, 
well recognized as it should be. It has been Nor does the responsibility rest here alone. 
noted in some cases of phthisis that urine He also believes that in the effort for a more 
became black on long keeping. The writer thorough course of instruction, a more elab- 
mentions several instances of uncertain orate curriculum, the medical schools have 
nature in which the urine has been dis- fallen into an error. The fundamental 
colored. He also gives a list of articles of principles of medicines and surgery are 
diet and drugs wdiich have the same effect, taught covering all other subsidiary depart- 
As to prognosis, it may be grave, as in the ments. Emphasis is placed on the history 
case of true melanuria; or as in alkapto- of disease, symptomatology pathology, diag- 
nuria the condition may be harmless, uosis and prognosis; but means of cure, by 
Between these extremes of morbid condi- the adaptation of suitable remedies, is slurred 
tions are various degrees of gravity. over or slighted and therapeutics is left to be 

taught the student, in the subdivision of the 
A Pica lor High Standard in Tiiera- scheme, by that teacher who gives instruc- 
peutics.— Dr. J. X. Upshur (The Virginia tiou in a general way from a general stand- 
Medical Semi- Monthly, Feb. 7, 1908) in a point; and the poor student, in attempting 
paper read before the Medical Society of to adapt it to some special affection, makes 
Virginia during its meeting at Chase City, a misfit and, unless very fortunate, never 
November, 1907, enters a strong argument gets it straightened out in the future. The 
against the idea recently advanced to omit therapeutics of the orthodox profession con- 
Therapeutics from the examinations before sists in the scieutific application of drugs 
State Boards. He says the influence of and other means of relief and cure, for good 
such views is harmful to the last degree. It reasons, based upon the indications in the 
tends to lower the standard of orthodox case, and knowledge of the physiological 
medicine to the level of the most sordid action of the drug exhibited in a definite 
commercialism, to abrogate and annul its and suitable dose. Such means of pre ven - 
dignity as a high and noble profession, and tiou and cure of disease as vaccination and 
reduce it to the level of a common trade fol- antitoxin have in thousands of cases, estab- 
lowed for what it will pay. It places it in lished their claim as a boon to humanity by 
a position where it no longer will stand for the prevention of smallpox and the cure of 
scientific truth, the skillful treatment of diphtheria. Yet, the Homeopath gives vac- 
disease, the relief of suffering humanity for cine taken from the arm in a certain dilu- 
the noble motive— the relief of a brother- tiou by the mouth, and very many repudiate 
man's physical woes. It especially enunc- antitoxin as a remedy for diphtheria alto- 
iates, under the mask of a seeming charity, gether. This may be done iguorantly, but 
a falsehood, far-reaching, and injurious to he asks, is it safe? 

the profession and its high aims, as the Again it is a known fact that homeopathy 
"Father of Lies" himself can be. An in its therapeutics, treats symptoms; the 
analysis of what regular medicine claims "similia similibus curanhir" is a cardinal 
through the administration of scientific principle of the dogma. Where comes in 
therapeutics is based on a sound and thor- the skill here? That the greater strength 
ough knowledge of drugs, in their physi- depends on the greatest dilution, is a patent 


1 69 

fallacy, emphasizing- criminal ignorance of 
the eliminative ability of the human body, 
as taught in the fundamental principles of 
physiology. Medicine must be given in a 
sufficient dose repeated frequently enough, 
and continued long enough, to produce its 
definite physiological action, or there can- 
not be, in the nature of things, relief or 

Osteopathy finds with all of its profound 
knowledge of fundamental branches — 
"anatomy, physiology and pathology, with 
all their subsidiary branches, including 
surgery and obsetrics" — a remedy for relief 
or cure of disease, only in massage in some 
form. Think of it, diphtheria trifled with 
by rubbing the throat, aiding more rapid 
absorption and resulting in more profound 
systemic infection; think of the danger of 
such manipulation in an appendicitis result- 
ing in abscess from delay and rupture, and 
fatal septic peritonttis from too rough hand- 
ling. The fallacy of massage of the chest 
in tuberculosis, or relief and comfort in 
organic disease of the heart — can an intelli- 
gent man claim this is safe? 

What of the Faith Curists? God save the 
mark! It would be puerile for an intelligent 
physician to suggest that their therapeutic 
measures could be safe under any conditions. 
We are told that "practically we have no 
quarrel" with these. Quarrel, no; it begs 
the question thus to express it. But we 
have a great responsibility which we can- 
not shirk, which demands to prove that, 
"its death-rattle" not only cannot be almost 
heard, but that there is a strong and virile 
body of the regular profession imbued with 
love and loyalty to it, who actuated by right 
motives and impelled by a deep conviction 
of the right, intend to fight for all time the 
inroads of fraud, and the attempt to lower 
its standard into the dust and mire of sordid- 
ness and selfishness, and the risk of the 
wholesale sacrifice of human life. Who are 
not ready to call a halt to the progress of 
medical science as manifested by its ad- 
vances in every direction at the present 
time? Our motto expresses our principles, 
"ever onward and upward to the light, ever 
in search of the truth, sustained by the 
principles of science, as illustrated by the 
benefit to humanity in the relief and cure 
of human suffering." 

The course taught by some of these schools, 
it is asserted, is more thorough than that of 
the dogmatic schools in their branches. 
Is it? For argument sake, grant that this 
is so! But with the therapeutics eliminated, 
it is like the play of Hamlet, with Hamlet 
left out. 

In conclusion, the writer pleads for high 
ideals in the standard of therapeutics. No 
department of medicine can be studied 

which, by the acquirements of a thorough 
knowledge, will redound more fully in bene- 
fits to suffering humanity, broadening as it 
does the resources of the physician and 
enabling him to administer remedies too 
scientifically aver to grope and blunder. It 
will give greater confidence in his own pow- 
ers for good, and so impress the sense of 
right that the base counterfeits are readily 
recognized and eliminated. So will the 
regular profession be redeemed from error, 
and firmly stand, established in truth and 
righteousness: The tendency of this age is 
to low standards. Never was there a time 
when the public mind was so familiar with 
vice and crime; never a time when consci- 
ence was less sensitive. Those who have 
borne the burden and heat of the day and 
had a wide experience, who have grown to 
love and reverence our great profession, 
must cry aloud, and cease not, -against all 
methods which tend to lower the standard 
of truth and right. So may it be that the 
coming years may be even better than the 

Hallucination.— McDonald (The Glas- 
gow Medical Journal) speaks of hallucina- 
tions. He remarks that the student of his- 
tory cannot help being struck by the part 
played by hallucinations in the story of 
human progress. In the annals of every 
nation, even from the remotest periods, we 
meet with hallucinatory episodes affecting 
the trend of popular thought and belief, 
and directing the conduct of the people. 
In some instances we find that the halluci- 
nations pertain to a particular individual, 
who interprets the hallucination as a mys- 
terious, divine revelation, an interpretation 
which begetting in its turn the secret belief 
in a divine mission, dominates the con- 
sciousness, leads to concentration of 
thought, a determination of purpose, and 
an accumulation of energy that urges on 
the hallucinated being to a realization of 
his dream, and sometimes makes him a 
leader of men. Thus, we find Joan of Arc 
in the history of France. But history also 
furnishes instances of hallucinations effect- 
ing masses of humanity. As example the 
author cites the hallucinatory epidemics 
that affected whole communities and armies 
during the holy wars, and here also one in- 
dividual, Peter the Hermit of Amiens. 
Biographers relate hallucinatory episodes 
in the lives of many illustrious men of all 
times, some of them men of undoubted 
genius. Martin Luther, according to the 
evidence of his own writings, was andoubt- 
edly subject to auditory hallucinations. So 
also was George Fox, the founder of the 
Society of Friends. Socrates, the ancient 
Grecian philosopher, is judged to have been 


the victim of hallucinations. Descartes, bites, and injuries of all kinds. The author 
after long confinement, was followed by an reviews the theories about hallucination, 
invisible person calling upon him to pursue He believes that the theory of the periphe^ 
the search of truth. It is recorded by Lorn- ral origin of hallucination holds good in 
broso that Von Ilelmont declared he saw a some, but not in all, instances. Even when 
guardian angel appear to him in all the the primary stimulus occurs without the 
most important events in his life. Xapoleon cerebrum, hallucinations are produced only 
was said to have had interviews with a after the censory centres, which are the seat 
familar spirit in the form of a little red man, of images, have been stimulated. A halhi- 
and he asserted he saw his star in every cination is never an entirely new creation 
great occurrence. Oliver Cromwell, while of the brain, but simply a reproduction of 
lying tired and sleepless in bed, had an ap- memory images, and, in cases where 
parition of the gigantic figure of a lady the hallucination seems new, strange, and 
who told him he would be the greatest man enigmatical, we have to deal merely with a 
in England. Johnson when at Oxford one new combination of its component ele- 
day heard his mother distinctly call "Sam," ments. So also in dreams, which are the 
though she was then at Lichfield. Cowper hallucinations of the sleeping state. It is 
was one day found, by his medical attend- an interesting and remarkable fact that 
ant with a penknife sticking in his side, hallucinations vary in different races and 
He believed he had heard a voice from at different periods of history according to 
heaven commanding him to take his own the knowledge and the dominant ideas of 
life. Pope one day asked the doctor at- the day and the people. The ancient Geeek 
tending him what was the arm which who had visual hallucinations saw gods 
seemed to come out of the wall, Byron and godesses, satyrs, driads, and nymphs, 
occasionally fancied he was visited by a The hallucinated individual of the middle 
spectre, but regarded it as the effect of an ages had visions of saints and guardian 
overstimulated brain. Goethe stated that angels, or saw the devil, after the manner 
one day he saw the exact counterpart of of that day, with horns, a goat's head, an 
himself coming towards him. These are arrow headed tail, and a pitchfork. In 
but a few out of many instances in the these later days visions of heaven or hell 
lives of great men in whom the existence are more Miltonic in character, and with 
of hallucinations seems to have been well the wider diffusion of knowledge and the 
established by the evidence of the facts, practical tendencies of advanceing civiliza- 
Hallucination should be defended as a sub- tion they are becoming less frequent and 
jective perception, a perception without a less definite than they used to be. So, too, 
corresponding objective stimulus. Ilallu- in the case of auditory hallucinations. In 
ciuations of hearing are those which we earlier times the hallucinatory voices were 
meet with most frequently among the in- interpreted as those of celestial beings or 
sane. They vary in character from simple spirits. Then the introduction of speaking 
noises, rumblings, moaniugs, hissings, tubes afforded a new explanation, and the 
whistlings, tinklings. musical sounds, barks sufferer was convinced that a secret system 
growls, cries, to the most complex of woods of tubes existed in the walls of his apart - 
and sentences. Hallucinations of sights ments. The introduction of the telegraph 
may assume the most diverse forms. The and then of the telephone was followed by 
most elementary -'appear as mere blurs, the transference of the voices to wires hid- 
clouds, sparks, flashes of light, while in the den in the walls, while in these days it is 
more complex, faces, persons, every variety no uncommon thing to find the victim of 
of object and scene may be portrayed in auditory hallucinations who declares that 
detail. Sometimes they are very indefinite, he is constantly receiving inarconigrams 
colorless, and phantomlike; at other times and wireless messages. The . author con- 
they are very vivid, highly colored, and eludes that no doubt a hallucination is an 
stand out in bold relief. Hallucinations of abnormal cerebral product, and if it were 
smell are not at all uncommon, and patients possible to divide mankind into two cate- 
often complain that they smell poisonous gories, those of sound mind and those of 
gases, chloroform, iodoform, faeces, putre- sound mind and those of unsound mind, 
fying substances, dead bodies, seminal dis- we should have no option left but to include 
charges, etc. Hallucinations of taste also the hallucinated with the unsound. Such 
occur, as when the patient tells us that he a division is, however, impossible. Sanity 
detects poison, blood, heces, etc., in his and insanity are comparative terms. Each 
food. Hallucinations of touch may be re- individual has a normal peculiar to himself, 
ferred to any point in the body. They vary and applicable to none other. Any at- 
in character and tntensify from creeping, tempt to make a division between ■ sanity 
pricking, cold, and burning sensations, to and insanity must be artificial and conven- 
electric shocks, caresses, stabs, blows, tioual in the highest degree. The existence 



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ofihallucination is certainly no criterion of 
insanity. We can, however, agree that 
when the subject of hallucinations fails to 
recognize these as anomalous productions 
productions of his brain, and allows his 
thoughts to be directed from their ordinary 
course, and his conduct to be regulated by 
the hallucinatory mental content, he is no 
longer of sound mind. 

Birth Traumatism and Epilepsy. — Yol- 
land (Allgem. Ztschrft. j. Psych.) among 
1500 artificial labors, was enabled to 
deterine the existence of epilepsy in 45 
patients, of 3 per cent, of the cases. Be- 
sides abnormal labor, faulty heredity as- 
sisted in the production of the epilepsy in 
13 cases. Tuberculosis of the immediate 
or remote progenitors was noted in six 
cases. Only three patients presented 
changes of the skull, which could be posi- 
tively referred to traumatic influences at the 
time of birth. In seven cases, without 
psychopathic heredity, there was infantile 
cerebral palsy, usually appearing in the 
course of the first to second year, together 
with the epilepsy. The traumatic injuries 
at the time of birth apparently create a 
predisposition of the brain for the evolution 
of the encephalitic process. In proportion 
to the great frequency of epilepsy, howeVer, 
birth traumatism plays only a minor part 
in the etiology of this disease. It is proba- 
bly to be regarded as a preparatory cause of 
the subsequent epilepsy in a small number 
of cases. 

The Treatment of Tetany with Para- 
thyroid Preparations.-~Loewenthal and 
Wiebrecht (Deutsche Zeitscrift f. Nerven- 
heilkunde), based upon numerous experi- 
ments, arrive at the conclusions that many 
cases of tetany are favorably influenced by 
feeding with thyroid and parathyroid gland. 
This favorable effect is due to the amount 
of parathyroid substance in the adminis- 
tered glands. In contrrdistinction to 
healthy individuals, these patients present 
no diminution of the body weight, or signs 
of thyroidism, as a result of the medica- 
tion. Congenital cases of latent tetany are 
based upon aphasia or functional weakness 
of the parathyroids, becoming manifestly 
tetanic as soon as the chemical equilibrium 
of the organism is disturbed by toxic or in- 
fectious interventions. 

One of the patients observed and treated 
by the authors was a woman about 40 years 
of age, who had suffered from a goitre since 
childhood. When she was 28 years old, 
rigidity of the hands was first noted, fol- 
lowed by severe spasms at the age of 37. 
Two years later, tetanic seizures and a psy- 
chical alteration made their appearance, 
together .with emaciation and a loss of 

strength. Removal of the right lobe of the 
thyroid gland was followed by improve- 
ment of the tachycardia and the general 
condition, but soon afterwards the tetanic 
disturbances increased, and were compli- 
cated by attacks of diarrhea. Administra- 
tion of thyroidin and rodagen brought only 
temporary improvement. In addition to 
the»symptoms of tetany, the patient pre- 
sented certain signs of Graves' disease, such 
as tremor, hyperidrosis, diarrhea, struma. 
A rapid subsidence of the tetanic attacks 
was observed to follow the administration 
of fresh thyroid and parathyroid glands. 
When the daily dosage of the powdered 
gland had been raised to 0.75 g. each day, 
the patient became entirely free from at- 
tacks, which returned as soon as the dose 
was diminished to 0.3 g. , disappearing again 
with the elevation of the dose. It was 
gradually demonstrated, through repeated 
experimentation with pure thyroid and par- 
athyroid substance, that the therapeutic 
effect is exclusively due to the ingestion of 
parathyroid substance. The symptoms of 
Graves' disease, and the psychic distur- 
bances, were not affected by the parathy- 
roid medication, which modified the tetanic 
manifestations alone. The same method 
of treatment failed in another case of tetany. 

The Pathogenesis of Hirschsprung's 

Neter (Muuchener medizinische Wochen- 
schrift) says that in spite of the numerous 
modifications which the conception of this 
affection has undergone in the last few 
years, it may be defined ac being a type of 
constipation appearing in earliest infancy, 
often during the first days of life, that is 
extremely obstinate, and is not rarely fatal. 
Anatomically there is always found a mark- 
ed dilatation of the lower portion of the 
colon, particularly of the sigmoid flexure, 
and usually also an abnormal dilatation of 
this portion of the intestine. Hirschsprung 
assumed that the dilatation and hypertrophy 
of the sigmoid were congenital, but some 
observers had advocated the view that there 
is a congenital dilatation of the lower por- 
tion of the colon with aplasia of the muscu- 
lature. Others have believed in an idio- 
pathic dilatation of the colon or in deficient 
tonus of a normal muscular wall in conse- 
quence of inadequate innervation. The 
author is of the opinion that the funda- 
mental condition leading to the develop- 
ment of Hirschsprung's disease consists in 
an abnormal length of the sigmoid and that 
the dilatation and hypertrophy are second- 
ary and not congenital changes. A case 
in point is reported which the author re- 
gards as affording evidence in favor of his 



Mucous Plaques; Prophylaxis and 

By Edward H. Skinner, M. D. 
St. Louis, Mo. 

The proper care of the mouth is a matter of 
importance in the control of the secondary 
symptoms of oral syphilis, especially in view of 
the fact that the average luetic patient has all 
too little regard for any hygienic measure. In 
anticipation of the early onset of the secondary 
oral patches it should be thu duty of the physi- 
cian to instruct his patients as to the proper 
prophylactic measures to be a 1 opted that the 
severity of these symptoms may be ameliorated. 

The first thorough examination of the new 
luetic case should include the careful inspection 
of the mouth and teeth, if we feel incompetent 
to judge of the condition of the teeth we should 
refer the patient to the dentist. The roughened 
edge of a tooth, or an unfilled cavity, may serve 
as an irritant in establishing a mucous patch. 
The dentist will instruct the patient as to the 
proper care of the teeth. The cleaning of the 
teeth after meals, to avoid the accumulation of 
debris, should be impressively taught. We 
should also realize that salivation may best be 
avoided by the attention to the teeth and gums. 

Anticipating the secondary symptons we usu- 
ally attempt to promote the general health of 
the individual by tonics and bodily hygiene. 
We should also try to increase the cellular re- 
sistance of the buccal membrane by local meas- 
ures. It may be well to consider means to this 
end at this time. Bartholow considers a num- 
ber of drugs to be used locally. Hydrastis can- 
adens is recommended as a stimulant to mucous 
membranes. It also has a valuable astringent 
quality and promotes the salivary secretions, 
llamameiis virginica is also valuable in advan- 
cing the prophylactic powers of the mucous 
membranes. Thymol and menthol have valua^ 

'eproperties, influencing fermentation and pu- 

trefaction, and also serving as antiseptic 
They allay the sensibility of the mucous mem. 
braues and arrest the retraction of the gums- 
Boric acid has decided antiseptic and deodorant 
properties. This acid was an important factor 
in the original Lister antiseptic method. Being 
very mild, it may be used in varying strengths 
without danger. Glycerine has a beneficail 
effect on all mucous membranes, inasmuch as it 
dehydrates and soothes any tissues it may touch 
Combination of the above remedies may be 
made that will serve rot only as valuable pro- 
phylactics, but also as curative agents in any in. 
flammation of the mucous membrane. But we 
should remember that the application will avail 
little if the patient does not assist their action 
by the careful cleansing of the mouth and teeth 
at frequent intervals, not being afraid to use 
the greatest remedy of ala — pure water. 

When once the mucous patch has asserted it 
self we should try to avoid the ulacerting and 
sloughing process that accompanies the oral 
syphilide. It is at this time that our pro phy 
lactic measures show their true worth. The 
mucous patch rarely spreads in the clean mouth. 
Foul secretions and decomposing food stuff favor 
the ulceration of the patces, The best local 
application for a patch is the silver nitratJ 
pencil. One application a day will usually suf- 
fice. An antiseptic mouth-wash should beused 
by the patient about every three hours during 
the day. Among the varous combinations on 
the market today one will fiind that Ivatharmon 
offer advantages'. The iniernal administration 
of mercury should be pushed. If we find that 
tne patches persists in spite of the above treat- 
ment we should try a short regime of the 
iodides. Very frepueutly the stubbornness of 
oral features of syphilis may be due to the 
mercury treatment. It is in these cases that 
the withdrawl of the metal and the substitution 
of the iodide, with the use of remedies to 
cure the ptyalittc symptoms, will afford relief. 
The Medical Mirrow. 



The Treatment of Dysentery. 

Sandwith ( Lancet) considers this ques- 
tion under the headings of "baeillary" dj r s- 
entery and "amebic dysentery." In the 
former type the bowel should be cleaned 
out with castor oil or magnesia. Rest in 
bed should follow, with warm clothing, per- 
haps a hot-water bottle, and certainly a pad 
of cotton wool on the abdomen surrounded 
by a flannel bandage. Physiological rest 
for the intestines, so far as possible, must 
be obtained by stopping all solid food and 
giving only small quantities of liquid every 
two or three hours. When the tongue is 
fairly clean, boiled or sterilized milk, pure 
or diluted with rice water, or peptonized, is 
the best food. The daily examination of 
stools, as in enteric fever, will tell you 
whether we are giving too much milk or 
whether it is necessary to peptonize it. 
When the tongue is thickly coated or the 
patient loathes milk, we may have to give 
chicken broth, albumin water, whey or rice 
water for a day or two. Alcohol will not 
help the dysentery and is bad for the liver, 
so should be withheld unless the heart re- 
quires it; brandy in such circumstances is 
the best stimulant. All food should be given 
tepid, neither hot nor cold, and eyen then a 
small judicious meal may cause immediate 
peristalsis and an action of the bowels. We 
must treat dysentery just as carefully as we 
would enteric fever if we wish to cure the 
patient. The author has hearty commen- 
dation for the serum treatment. In the 
amebic variety of the disease the same gen- 
eral regimen is followed as above outlined. 
We may give bismuth by the mouth, with 
tanniger or some astringent added Many 
still rely on ipecac in combination with 
opium. Calomel is not indicated. Sulphate 
of magnesia may be given alone or com- 
bined with sulphate of soda. Rectal irriga- 
tions are of great value and should be begun 
early. Quinine may be used, 1-500 or 
1-1000, Silver nitrate, 1-1000, or copper 
sulphate in the same strength. 

A Plea for Uniformity of Conditions In 

Gerrard (Lancet) complains that the 
lymph used for vaccination is under no 
official control or supervision except in case 
of public vaccination. The private prac- 
titioner may obtain his vaccine from where- 
ever he likes, he may carry out the proced- 
ure in whatever way he may wish, and he 
may scarify in as many or as few places as 
his convictions or his patients dictate. He 
may also, if he cares to, return the slightest 
reaction as successful vaccination He is 
under no supervision whatever. In such an 



Original Communications. 

Are Our Rights Threaten- 
ed? by Dr. H. C. Buck, 
Friars Point, Mississippi, 12L 

Confusion and Errors in the 
Diagnosis of Rheumatism, 
by Lewis M. Gaines, M D , 
Atlanta, Ga., 142 

Delirium Tremens, by Dr. 
Robt. S. Carroll, Ashe- 
ville. N. C 145 

Ectopic Gestation, bv John 
W. Dillard, M.D.. Lynch- 
bu.-L r . Virginia, 135 

Malformations of ih Mouth 
and Cleft Palate, by M.F. 
Coomes. M. D., Louisville, 
Kentucky 123 

Massive Quinine Dosage in 
the Treatment of Pneu- 
monia, by R. L. Payne, Jr., 
M. D , Norfolk, Virginia, 129 

Open Method Treatment of 
Lpitbeleotna on a Muco- 
cutaneous Surface, by W. 
D. Witherbee. M. P.. 
Charlotte, N. C 122 

Presidential Address, by 
Dr. Stuart McGuire, Rich- 
mond, Virginia 136 

Retained Placenta — Report 
of a Case, with Remarks, 
by J. N. Upshur, M. D., 
Richmond, Virginia, 133 

Sarcoma of Colon, by Dr. 
C. M. Strong, harlotte, 
N.C., 133 

The Position of the X-llav 

Specialist in the Field of 
Medicine and Surgery, by 
Dr. A. L. Gray, Rich- 
mond, Virginia, 128 

The Treatmentof Epilepsy, 
by J. Allison Hodges. M. 
D., Richmond. Virginia, 139 

Tubal Pregnancy, by W. P. 
Whittim/ton, M.D". Ashe- 
ville, N.C 126 


A n O -itenoa fch Shot, 1 •'>(") 

Amebic Dysentery loo 

Charlotte Sanatorium 
T raining School for 

Nurses 151 

Dr. L. L.' Ardrey 158 

Five Children at a Birth. . . 157 

How Will R Work? 157 

Report of the North Caro- 
lina Board of Heal th, 15ii 

Small -Pox, 158 

The Fight Against Tuber- 
culosis, 158 

The Tri-State Medical Soci- 
ety Meeting, 151 

Vivisection,. 153 

Watts Hospital, Durham, 

N. O, 156 

Yellow Fever, 157 

Review of Southern Medical 
Literature, 158 

Book Notices. 

A Great Opportunity for 
Sufferers from Nervous 
Troubles 16* 

Diseases of the Heart, by 
Prof. Th. von Jurgensen, 
of Tubingen, 

Eleventh Biennial Report 
of the North Carolina 
Board of Health. 1905-6, 

Practical Fever Nursing, 
by Edward U. Register, 
M.D.. Charlotte, N. P.. . 

Surgery: Its Principles and 
Practice, edited by W. W. 
Keen, M D., . . . .' 

The Pyonex: Its Theory 
and Practice, by W. B. 
Rule, M- LLCS., L.R.C.P. 


A Plea for Higher Standard 

in Therapeutics 

Birth Traumatism and Epi- 

Diabetic Neuritis 

Ha lucination, 

Locomotor Ataxia, 

Observations on Pirquet's 
Tuberculin Reaction,. . . . 

On Biack Fever 

The Heart Rhythm, 

The Surgicai Treatment of 
Cerebrospinal Meningitis 

The Mechanism of the Re- 

The Treatment of Tetany 
withParathyro.d Prepar- 

The Pathogenesis of Hirsch- 
sprung's Dii 

Vaginal Cyst 






Influence ef Diet on tho Liver. 

Watson ( Lancet) details the results of 
two series of observations. One experiment 
consisted in feeding a large number of rats 
on an exclusive ox-flesh diet, this being 
essentially a mixed diet of protein and fats. 
In this experiment it was observed that the 
percentage weight of the liver in meat-fed 
rats was, as a rule, considerably greater 
than in the control bread-and-milk fed sub- 
jects, the difference beiag such as could not 
readily be explained by mere variation in 
the blood-supply of the organ. An objec- 
tion may be raised that the use of an ex- 
clusive flesh diet is too unnatural a regime 
to allow any deductions to be drawn which 
can be applied to conditions obtaining in 
man. To meet this objection attention is 
therefore more particularly directed to the 
detailed results of a second series of obser- 
vations, which consisted in comparing the 
percentage weight of liver tissue in wild 
rats living, it is assumed, on a highly nitro- 
genous dietary with those of an equal series 
of animals obtained chiefly from the same 
source which were fed on a diet of bread 
and milk in fixed proportions, a diet which 
contained a much smaller proportion of 
nitrogenous food. This diet of bread and 
milk is one which has been proved to be 

well adapted for the growth, general health, 
and fertility of the ordinary tame rat. 

Prevenllon of Scarlatinal Nephritis. 

Thompson speaking in regard to the use 
of a prophylactic drug against the nephritis 
of scarlatina says that urotropin is the only 
one which has proved itself of value. Of 
47 consecutive patients treated with this 
agent by the writer, not one had nephritis 
and only one exhibited albuminuria. These 
facts are considered encouraging enough by 
the author to suggest the further use of the 
drug in scarlatina. Patients treated with 
hexamethylenetetramine were less fortunate 
in escaping nephritis, and the writer holds 
this drug to be not an exact equivalent of 
urotropin when considered from the point 
of therapeutic results. It is suggested that 
all instances of scarlatina be treated from 
the beginning with 5-grain doses of uro- 
tropin three times a day for children up to 
twelve years; for patients above this age 
7}4 grains thrice daily are advised. Gener- 
ous dilution of the drug with water is neces- 
sary and the treatment should be continued 
to the end of the twenty-eighth day of the 
disease. — Edinburgh Medical Journal. 

Another explanati 

ion tha 

fthe occurrence c 

1' thes( 


important matter as vaccination, where the leisi 
benefit to the patient is not immediately give 
apparent, it is very serious if the operation j s the chronic carbonic acid poisoning which 
is carried out by any means not ideal from r( , sul| sfrom partia] asphyxiation. 
a surgical point of view. All these objec- 
tions could be met, he claims, by having Epilepsy in Chaildhood. — Keeling (Brit. 
vaccinatum completely under State control. j 0U r. Child. Dis.) saps that the pathology 
He believes that the cases handled by the of ep ilepsy appears to resemble in some re- 
public vaccinators are better protected , ., , „ , , ,. . . , 
1 . . , , t1 r , , spects that of cerebral diplegia, chorea, para- 
agamst variola than are those of the aver- / . ,. ' ' 
age private physician. Comparison of ^ ,s agitans, neurasthenia, myoclonus and 
official and non-official lymph with regard migraine. 

to bacterial content were much in favor of Etiologically, rickets is an important factor 
the formes, as shown by tabulated results, in the causation of epilepsy. 
It must be remembered that the author is A varie ty f epiiepsv, which may be term- 
speaking of conditions in England In the ed tQxic n] |s chiefl tl . . intestina , 
I nited Slates the lvmph manufactured by ... 
the civic authorities can be purchased bv LI ori § m - 

local physicians even for private patients if Reflex '-'I'depsy is apparnetlj rare; peri- 
the latter are toe poor to pay, and the charge pheral irritation probably plays a very small 
has been made so low that it can almost be part in the production of the fits. 
disregaeded. The effect of measles on epilepsy is nn- 

Alimentary Levulosuria in Diptheria.-- certain. 
BYanchetl (Rev. di Clin. Ped.) cays that one Chorea is very rarely found associated with 
o fthe lastesl methods of indicating the per- epilepsy. 

fection of function of the liver is alimentary Infantile paralyses, especially the congeni- 
levulosuria. The author has made observa- tal fonns, are closely related to epilepsy. 

of this method in forty-one cases, thirty- An injury or a fright is frequently the 
three of diptheria and seven of angina. Of exciting cause of a fit. Instrumental delivery 
these, thirty gave postive results when levu- may be followed b yparesis with subsequent 
lose was administered by mouth and tests epilepsy. 

were made. The author concludes that the Enuresis is an occasional sequela' of epi- 
tesl for levulosuria in diptheria, both in the lepsy. 

heighl of the disease and in convalescence is The three affections most frequently found 
in mosi positive. It is always positive in in the family history of epileptics are 
cases of diptheritic paralysis. It is not in- epilepsy, migraine and alcoholism. 
fluenced by slighl uepthritis, bronchopneu- Migraine appear sto be very closely allied 
moiiia. fever, or general symptoms. to epilepsy, both in the family history and 


The differential' diagonsis between Men- 

Pathogenesis of Nervous Complications in 

Pertussis.— Durante (La Pediatria) tells us . 

.. ,. „ lere s disease and epiiepsv is occasionally 

thai the various complications ol nervous . r r ' 

... . m , . , difficult, 
origin in pertussis are not rare, lhey consist 

of paralysis, peripheral, contral, spiral, and Goiter in the New-born.— Plauchu and 

bulbar, neuritis, and special sense troubles. Richard (Gaz. des Hop.) find that goiter is 
The predisposing causes are debility, loss of not exceedinly rare in infants. Its size may 
sleep, loss of nourishment from vomiting, and vary* from that of a small mut to that of 
the specific infections elemenl of the disease the thumb. It extends across the neck, or 
acting .m the system of the child. The im- is shaped like two pyramids with the apices 
mediate causes are the violent cough, which, upward and backward. It may be vascular. 
increases the blood pressure at the lime of which is the commonest form, parenchy- 
the paroxysm, changes in the circulation, and matous, or cystic. „The vascular tumors are 
hemorrhages into the brain and nervous cen- absorbed soon after birth. They are coul- 
ters. These lesions are sudden in onset, short posed chiefly of dilated veins. Large sinuses 
in duration) and generally entirely recovered are found in the glands and few islands of 
from. The commonest symptom is convul- cells. The parenchymatous form is rare, and 
sions, which may be slight or severe enough only one case is reported after autopsy. The 
to cause death. The frequent recovery indi- trachea ay be so much compressed as to pro- 
cates that there is no permanent organic duce cyanosis. The esophagus muy also be 




d. Ii 

general the tumor 

ditary, and congenital. Goiter in the fetus 
is sometimes a cause of dystocia. The symp- 
toms aside from the presence o fthe tumor 
aie dyspnea, cyanosis, difficult in swallowing, 
feoagb, and refusal to nurse. This affection 
in the new-horn child is exceedinly grave. 
Death results in the majority of cases, de- 
pending on tracheal stenosis. The goiter may 
he gradually absorbed. It may be necessary 
to invert the infant to relieve the attack of 
cyanosis, and tracheotomy may become ueces 
saiy. Thyroidectomy is too severe an opera 
tion to be performed in such young children. 
Exoihyropexy is to be preferred and has 
good results. 

Phagocytic Power of the Blood in Infants. 
Finizio (La Pediatria) tested the phagocytic 
power o fthe blood in an infant attacked by 
empyema due to the staphylococcus pyog- 
enes aureus, and in one suffering only from 
slight dyspepsia. He used staphylococcic pus 
from another source fo rcomparison pus from 
another source for comparison tests. Th? 
index in the baby with empyema was always 
higher than in that of the other baby, it 
was higher in both babies for the empyema 
pus than for the other sample. It was always 
within the limits observed by Wright. The 
author concludes that the index is lower for 
the more virulent staphylococcic, which Is 
less subject to the phagocytic power than 
those of weaker virulence. The phago-cytic 
index is always higher in the healthy child. 

Bier's Stasis Method in Osteomyelitis and 
Tubercular Osteoarthritis.— Costa (Gior. In- 
ternat. delle Sei. Med.) has used the passive 
hyperemia method of Bier, produced by elastic 
band around the limb above the joint, and 
applied 1'ioni one-half hour to three or five 
bousr in cases of osteomyelitis and tubercular 
osteoarthritis. In cases of much disorganiza- 
tion, with many sinuses, and much necrosis, 
it is a positive disadvantage, and destroys 
tissues that might be useful in an operation 
for excision of the joint. In closed lesions 
not communicating with the external air the 
method is of value, and some excellent results 
have been obtained. Nsed after operation the 
method is of value, especialy after a bloody 

Status Lymphaticus with Enlarged, Thymus 
— Priedlander (Arch, of Ped.) reports such 
a case successfully treated b ythe x-ray at 
to monts of age. Twelpe exposures were em- 

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ployed, the first three for one, three and four 
minutes, the rest for five. The thmus and 
bronchial lymph nodes diminished greatly in 

The subsequent development of the child 
was normal, and the external lymph nodes 
and spleen are no longer enlarged. 

Again, the fact that the child could success- 
fully witchand such a trauma as the removal 
of the tonsile and adenoids without shock 
would speak for a resitance fully np to the 
normal within two years after the x-ray treat- 

Ovarian Cyst in Infant. — MacGillivray 
(Lancet) records the successful removal of a 
multilocular ovarion cyst, the points of in- 
terest being: 

1. The age of the patient at the time of 
operation, eleven months, the tumor having 
been first noticed at the third month. D'Arcy 
Power's case is therefore the only younger 
case recorded, his patient being four months 
old at the time of operation ; but in his case 
the cyst was unilocular, with a long pedicle, 
incision. 2. The enormous size of the tumor 
mass it as in reality made up of two multilo- 
cular cysts with flattened sides, attached the 
one to the other by loose connective tissue, 
thus raising the question of its being a double 


ovarian cyst; I In state of the child at the bul from thai time onwards improvement 
time of the operation prevented investigations was rapid and complete. 

being made as to the presence or state of the The case convinced him as strongly as any 
oilier ovary. 3. The retroperitoneal position single therapeutic observation could, that the 
of the tumor, as shown by the appendix, withdrawal of an ounce of cerebrospinal fluid 
cecum, and escending colon lying' in front was responsible for the cure of this child. 
of it and stretched over its surface, and the And since the pressure was normal, it seemed 
fact that the posterior layer of the periton- legitimateto conclude that it was hyperemia 
cum had to be torn through in order to enu- which had favorably affected the nutrition 
cleate the tumor As Kelly slates, such a of the disordered nervous tissues in some- 
position points to the tumor being sarcoma- what the same favorable manner as it has 
tons and irectly contraindicates an ovarian been shown by Bier and others to act iu 
origin. 4. The uneventful recovery of so more accessible regions of the body. 
young a child from such a severe operation. Diabetes in Children. — Fletcher (Practition- 

Cerebral Hyperemia as a Factor in Thera- er) finds from the records of St. Bartholo- 
peutic Action of Lumbar Puncture.— Eve mew's Hospital for twenty-two years that 
(Lancet) during the past few years has al- twenty-nine or 5.2 per cent of the diabetic 
ways measured the intracranial tension dur- patients were sixteen years of age or less, 
ing a lumbar puncture, and has been led to seventeen being males and twelve females, 
the provisional conclusion that relief of ten- Heredity must be regarded as an important 
sion should be given therapeutic credit only in etiological factor. The Hebrew children do 
cases where the hypertension is considerable; not seem to show as great a liability to the 
and that where the pressure is normal or disease as do adults. In the majority of 
slightly raised the benefit which sometimes children no exciting or predisposing cause 
results from lumbar puncture should be ascrib- can be found. Skin affections are not very 
ed to other causes. He advocates the predo- common in diabetic children. Vomiting is 
minant claims of one factor which has not an important feature, constipation is common. 
received attention. That factor is the marked Temperature is often subnormal, especially in 
passive hyperemia of the cerebrospinal vessels severe cases with attacks of drowniness. The 
which must inevitably result from the removal course of the disease is conspicuously shorter 
of any considerable quantity of cerebrospinal than in the adult. In many cases the final 
fluid. For, owing to the uncollapsible bony symptoms occur without warning, often after 

enve?o] f the central nervous system and some slight cause such as constipation, 

to the inextensibility of its nervous and liquid diarrhea, toothache, a boil or abscesses. Con- 
contents, it follows that for every ounce of vulsions are rare. The treatment differs in 
cerebrospinal fluid removed an exactly equal no essential from that of adults. The chief 
quantity of blood will be added to the contents distinction between the treatment of a dia- 
of the cerebrospinal vessels. betic child and of a diabetic adult, on which 

lie reports an illustrative case of tetany special emphasis should be laid, is that la 
treated by lumbar puncture, a healthy boy ,li( ' case of ,ll(1 child, a strictly carbohydrate- 
£om years old. The onset was acute a fore free det can rarely, if ever, be adopted with- 
tiiahl bciui( admission. out bringing about an increase in the acetone 

Treatment for twelve days consisted of an d acet-acetic acid reaction, and a greater 
tonics with open all day and night. Then liability to coma. 

five day- ( faperients and vermifuges in re- Noctambulism and Automatism in the 
spome to a history of worms eight weeks Child.— Dauchez (Arch, de Med. des Enf.) de- 
pjceviously Next, eleven days of energetic scribes somnambulism as it occurs in the child 
'"ialive treatment with chloral and bromide, as a reflex of cerebral or medullary origin, an 
The case ha. ! now a duration of six weeks association of ideas that are habitual, in which 
with a month of hospital treatment without judgment does not intervene. Noctambulism 
the slightest improvement. The writer of dream in action is frequent in the child, 
stopped all other treatment and tried the while diurnal automatism is peculiar to the 
withdrawal of an ounce of cerebrospinal fluid adult. It is observed in children of parents 
by lumbar puncture under chloroform. The that are alcoholic, epileptic or degenerate. 
pressure was normal (200 millimeters of Ambulatory automatism in which the subpect 
water). Next day the child was more rigid, escapes from himself is a symptom of adult 




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iit'c almost exclusively. Noctambulism in 
children is of all degrees from simple gesture.* 
to rising and walking about. A reflex is not 
a malady especially when there is no heredi- 
tary diathesis and the prognosis is good in 
these cases. Noctambulism appears in adole 
scence not in infancy In this cerebral reflex 
there is a dissociation of the psychical cen- 
ters the senses alone remaining awake and the 
higher brain functions such as judgment re- 
maining asleep Diurnal automatism, or ambu- 
latory automatism is a state in which tho 
patient escapes from himself, goes out, and 
remains . away for some days, acting in the 
person of another self. This condition does 
not exist in children. The child of epileptic, 
or hysterical parents enters on daylight som- 
nambulism and remains unconscious of him- 
self. This form is intermediate between noc- 
tambulism and ambulatory automatism. Am- 
bulatory automatism may exist in the adoles- 
cent and is of worse prognosis. With a here- 
ditary taint automatism may become diurnal 
ami perist through life. 

Temperature of Infants. — Nobecourt (Rev. 
Mens, des Mai de I'Enf.) finds that the nor- 
mal temperature of the infant does not vary 
in different parts of the day. In adults there 

is a slight rise as the day advances, but in 
the child he finds that this rise does not 
occur until the child has begun to be active. 
He believes that this change in temperature 
has to do with the bodily activity in those 
that exercise. In disease the infant has the 
customary atfernoon rise, as in gastroenteric 
In the infant the same temperature is main- 
tained day and night. Feeding has no effect 
on the temperature. The disappearance of 
monothermia indicates a pathological condi- 

Mastoiditis in Infants — Nove-Josserand and 
Jacod (Arch. Gen. de Chir.) say that up to 
the age of two years ethmastoid process and 
cells should be considered as a part of the 
tympanic cavity. The meatus is large, short, 
and rectilinear and oblique from above back- 
ward, the Eustachian tube is large, short, 
streighter and more open than in the adult. 
The recumbent position of the infant allowb 
of drainage from the pharynx into it, and 
thence into the ear. This infection of the 
mastoid occurs easily. The infection is gen- 
erally unpreceived. It may result from ade- 
noids, otitis, and tiaso-pharyngeal catarrh. 
The microbic cause is unimportant, but tho 
general health is important, since some con- 


ditions such as tubersulosis, infectious diseases The Correct Method of Interruption of 
of childhood, and gastroenteritis predispose Pregnancy. — Hannes (Munch. Med. Woch.) 
to mastoiditis. Age lias no great influence, discuesses the best method of interrupting 
The dimensions of the mastoid cell, ' which pregnancy when the needs of the mother re- 
is often single, are about the same as in the quire that it shall he terminated. He be- 
adult. The condition found in mastoiditis is lieves that the best ethod is one that shall 
a pus pocket at the hot torn of which is produce pains of a normal character and an 
denuded bone. There are three forms: mas expulsion of the ovum by the natural means. 
toiditis at the point of the process, mastoiditis The ganglia that control the uterine pains are 
involving the entire process, and mastoiditis on both sides of and behind the cervix, slight - 
I hat is diffuse and involves only the surface, ly below it. It is by insults offered to these 
Symptom sare slight; they are the appearance ganglia by the pressure of the child that the 
of a retro-auricular collection of pus, with onrmal pains are produced. The means of 
little pain, and slight fever. As for complica- interrupting labor should operate in the same 
t ions, sinus involvement is not important, manner. The apparatus should press on these 
facial paralysis is rare, and meningitis occurs same ganglia. Such an apparatus is to be 
occasionally. The prognosis is good except found in the cigarshiped rubber bag or the 
in tuberculous subjects. Treatment consist balloon dilator, ags of different, sizes can be 
of evacuatio nof the pus, scraping away the used and the pressure varied by differences 
diseased bone and drainage. in the fullness of the inflated bags. The 

result is the excitation of rhythmical contrac- 
Koch's Old Tuberculin in Gynecological ti(,lls - aild a physiological labor. A living 
Diagnosis.— Pankow (Zent. f. Gyn) sums up and viable child may thus be delivered. This 
a series o fthirty-two cases of tuberculosis of method is infinitely preferable to rupture of 
I he abdominal organs in which the diagnosis the membranes allowing of the drainage off of 
was assisted by the injection of the old form the lif l U01 ' amnii > thus dom S awa Y wit b the 
of tuberculin made by Koch. In all these natural dilating force of the bag of waters, 
cases the operation acted as control on th<5 This when [t l^PPens before labor is begun 
diagnosis. When there was a local reaction in an . v case Induces a very slow and tedious, 
from the injection it was shown by pain in not to sa . v dangerous labor. The whole labor 
the abdomen and profuse diarrhea. A general is completed with the baloons in less than 
reaction was shown by fever, chills, nausea, twenty-two hours at the longest, while rup- 
vomiting, etc. Only patients having no fever lure of the membranes delays it from seventy 
were injected. The thirty-two patients may ,n ei 8' ht y ll0urs - This method has been used 
he divided into four classes: 1. Those in f,,r twelve years at the Frauenklinik in Bres- 
which neither reaction nor histological diag- lau > and there has never been a bad result. 
nosis showed tuberculosis. 2. Those in which The method may be thoroughly aseptic when 
I he diagnonsis was not established by the in- properly conducted. The ending of labor is 
jection. :5. Those in which reaction and his- normal and spontaneous. The method is ab- 
tological diagnosis agreed. 4. Those in which solutely free from danger, and is applicable 
with a negative reaction diagnosis, histological at an . v time during pregnancy, although it is 
examination showed tuberculosis to be pre- not advisable to use it during the first two 
sent. The histories o fall these cases are months. When a more rapid procedure is de 
given. Of thirty-two cases in which tubercu- sizable to save the life of the mother the 
iosis was astablished by examination the re- author makes use of vaginal Cesarean section. 
Mill of I he tuberculin injection was positive He considers this preferable to the use of 
in twenty-four, that is 75 per cent. It was cervical incisions or of Bossi 's dilator. The 
negative in nine, 25 per cent. The local latt<>1 ' is Iikelv to leave tears that will not 
action was absent in twenty of the cases that Qeal easily, while the vaginal Cesarean sec 
showed genera] reaction. The author slates ti,,u 'caves clean-cut wounds that can be per- 
that according to his observations if both lV, 'tly sutured. The vaginal section is not 
local and general reaction are absent in all desirable when there is placento praevia, since 
probability tuberculosis is absent from gen- fc 00 free hemorrhage is likely to supervene. 
itals and kidneys. Local reaction seems to be Induced Labor and the Quickest Method of 
of Hi tie value in the diagnosis of abdominal Producing it with the Mechanism of Dilata- 
tuberculosis. tion— Biss* (Gyn. Rund.) tells us that he has 



a'ol changed his views as to the best method 
of artificial dilatation in the seventeen years 
since he tirst described his dilator, but that 
tie has several times modified the dilator as a 
result of experience in its use. The dilata- 
liun may be accomplished in from one-half to 
I wo hours. He believes that the longer time 
is preferable. If danger presses, the opera- 
tor amy hurry the dilation. As soon as the 
instrument is introduced it acts as a foreign 
body and causes energetic contractions. The 
dilator has a dynamic as well as a mechanical 
effect. Diliation by the hand is not only diffi- 
cult for the operator, but in some cases abso- 
lutely impossible, while it takes loo much 
time, in some cases thus endangering the life 
of the patient. The mechanical power of the 
dilator lies in the crucifix form of the 
bianchcs. Many dilators have been proposed 
which are faulty in their construction, and 
the bad results of their application have 
brought the method into disrepute. The in- 
strument should never be introduced through 
.•! speculum nor should the uterus be held 
with forceps. It should alwyas be introduced 
along the hand and never blindly. Twoai'd 
the end of pregnancy at least an hour should 

be consumed in dilatation and the position 

of the blades should be changed two or three upon tne site of origin, the effect of gravity, 
times to avoid tearing the cervix. The ends an( j t jj e guiding direction of the viscera and 
of the blades should be more blunt and longer omentum, both static and peristaltic. The 
than they ewre al first made. The dilator accumulation of the infective fluid occu- 

^fP£C/fy TYREES 


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may be used with submucous fibroids in the 
uterine canal to permit the removal of tlm 
growth. The author believes that the method 
stands today as a good one, and that the 
failures of bad and improperly applied in- 
struments should not be allowed to militate 
against its use with proper instruments ap- 
plied in a proper manner. The indication is 
to improve the instrument and to teach the 
accoucheur its proper use. 

Acute Generalizing Peritonitis. — Carwar- 

pies the true pelvis; the omentum becomes 
fixed to the diseased focus, and tends to local- 
ize t he fluid by forming an omental roof. 
The writer commends the practice of draining 
serous collections as well as the purulent 
ones, ami if there be any apprehension of 
subsequent .infection of any proximate favor- 
ite site, to anticipate this by putting a drain- 
age tube into that area, the favorite pools 
being pelvic, right and left lumbar, and right, 
and left subphernic. Two recent improve- 
ments in the treatment of these cases deserve 
British Medical Journal, uses the term notice. The Fowler position consists in pla- 1 - 

'• generalizing' peritonitis" to cover all those 
cases of rapidly spreading peritoneal infec- 
tion, usually from a primary focus. The com- 
mon sites of origin of such spreading peri- 
tonitis are the vermiform appendix, the uter- 

ing the patient in the upright sitting posi- 
tion as soon as possible at the time of or 
immediately after operation, so that the 
peritoneal exudation may gravitate to the 
lower abdomen, where drainage is provided 

me appendages, and the gastroduodenal region for, far away from the more dangerous 
by reason of infection or perforation. Within epigastric areas. Murphy's treatment cou- 
the peritoneal cavity there are certain poten- sisls of (1) rapid removal of the focus of in- 
lial spaces which may become converted info feetion, with little disturbance of the periton- 
izes by accumulation of fluid therein. Which aeum, and closure of the hole in, the gut* 
of these spaces is primarily involved depends (2) drainage (a) suprapubic, (b) through the 



North Carolina Medical College 


Oldest Medical College in the State 

Spring Qysz, 


REGINNING April 1st, and lasting about six weeks, a Special quiz course will be 
given, designed especially to give a review of the fundamental branches to those 
expecting to take the State Board Examination and other graduates wishing to "brush 
up" on these branches. 



Professor of Neurology and 

Practice uf Medicine. 

I. W. FAISON, M. D. 

Professor of Pediatrics and 
Clinical Medicine. 

Professor of the Principles 
and Practice of Medicine. 

W. O. NISBET, M. D. 

Professor of the Diseases of 

the Digestive System and 

Dean of the Faculty. 

B. C. NALLE, M. I). 
Professor of Materia Medica 
and the Physical Diagnosis 

R. L. GIBBON. M. D. 

Professor of Practice of 


Professor of Principles of 


Professor of Rectal Diseases 
and Genito-L'rinary Surgery 

Professor of Diseases of the 
Eye, Ear, Nose, and Throat 


Professor of Dermatology, 


Professor of Gynaecology. 


Professor of Obstetrics and 

Clinical Gynaecology. 


Professor of Anatomy. 


Professor of Chemistry and 



Professor of Pathology and 



Clinical Professor Surgerv . 



Assistant in Surgery 


Assistant in Eve, F)ar, Nose 

and Throat. 

Assistant in Medicine. 

Assistant in Gynaecology. 


Assistant in Genito-Urinary 


Assistant in Anatomy. 


Assistant in Anatomy. 

Assistant in Chemistry. 

Assistant in Clinical Micro- 

For Catalogue address A.J. CROWELL, M. D. ( Charlotte, N. C. 

operation incision; (3) rapid operation, pre- 
ferably through (lie rectum, and no sutures 
:"•(• l>u! i": (4) no food is given by the 
mouth for I wo or thr lays; and (5) continu- 
ous saline infusions by (lie rectum. The ob- 
jeci of these las! is not to cause the bowels 
i" act, hut merely to keep a supply of a few 
inches of saline fluid always in (lie rectum. 

Sl&ns of Death. 

The following have been suggested as 
methods of deciding whether death has 

a. Tie a string firmly about the finger, 
ff the end of the finger becomes swollen 
and red, life is not extinct. 

b. Insert a bright steel needle into the 
flesh. If it tarnishes by oxidation in the 

course of half an hour, life may be consid- 
ered not extinct. 

c. Inject a few drops of liquor ammonia 
under the skin. During life a deep red or 
purple spot is formed. 

d. Moisten the eye with atropine. Dur- 
inn life the pupil will dilate. 

e. Look at a bright light or at the sun 
through the fingers held closely side by side. 
During life the color is pink; after death a 
dead white. 

/. After death a dark spot is said to form 
gradually on the outer side of the white of 
the eye from drying of the sclerotic, so that 
the dark choroid shows through. 

g. Putrefaction is an absolute sign of 
death. Better delay for it than run any risk 
of burying alive. — Selected, 

The Charlotte Medical Journal 



No. 4 

Heart Block.* 

By h. B. Newell, M.D., Professor Pathology North 
Carolina Medical College, Charlotte, N. C. 

In view of the considerable and very real 
interest which has been manifested by the 
scientific world during the past few years 
in the domain of heart pathology, any 
account of the work done by investigators 
along this line and the results of their re- 
searches can scarcely be otherwise than 
worth while to the practitioner. It has 
therefore seemed not inappropriate that I 
should attempt to gather into some sort of 
order a few remarks on one phase of this 
subject, hoping that it ma}' stimulate a 
somewhat closer observation on the part of 
those of us who daily come in contact with 
the clinical manifestations of disease. With 
the text-book descriptions of cardiac arryth- 
mias we are more or less familiar, but there 
are things which have not yet been incor- 
porated into text-books generally, but which 
nevertheless have received the stamp of 
authoritative approval which means that 
they will eventually become common knowl- 

The causes of irregularities of cardiac 
rhythm and their pathologic significance 
are but imperfectly understood as yet, 
although wonderful advances have recently 
been made toward their explanation. If, 
therefore, I may bring to your attention 
some of the later ideas which have a genu- 
ine foundation in anatomic findings, it may 
not be entirely profitless. The condition to 
which these lines are devoted, while not 
exceedingly common, is yet not so rare and 
it may be possible that cases hitherto inex- 
plicable could assume renewed clinical 
interest in the light of better understanding. 

Heart block is comparatively a newwordin 
medical terminology, but the condition to 
which it is applied is certainly not a clinical 
curiosity; rather is it a fairly well defined 
entity. Before defining the term, which is 
perhaps already more or less familiar to 
those present, it may be profitable to inquire 
into the normal mode of action of the heart. 
In an organ acting with such precision 
there should be found precise laws govern- 
ing and explaining the phenomena of its 
action. As yet it is not possible to explain 
all these phenomena, although some things 
are known and formulated very definitely 
concerning the heart's action. But beyond 

*Read before Meckl 
ety, January 21, 190S. 

iburg County .Medical Soci- 

these many facts are known, the explana- 
tion of which are matters of dispute; and 
still others which merely give ground for 

The study of the physiology of the heart 
beat has led to the formulation of two dis- 
tinct theories as to the rhythmical contrac- 
tion of the heart muscle. We know that it 
possesses an inherent tendency torhvthmical 
contraction, this being one of the properties 
by which it is physiologically differentiated 
from other kinds of muscle tissue. Avoid- 
ing any attempt to explain this phenomenon, 
we may add another fact; the contraction 
of the heart muscle begins, or is originated, 
in the mouths of the great veins (venae 
cavae) of the auricle, this resulting in the 
simultaneous contraction of the auricles, 
immediately followed by a simultaneous 
contraction of the ventricles; then there is 
a pause during which the heart is at rest. 
Clinically the normal rhythm consists in a 
long sound, a short pause, a short sound 
and a long pause. It matters not how or 
why the contraction originates, what con- 
cerns us most is the method by which the 
impulse, once it has arisen, travels over the 
auricles and from them to the ventricles. 
On this point two theories have arisen: the 
neurogenic and the myogenic. 

According to the neurogenic theory the 
impulse originates in and travels by way of 
nerve cells. The stimulus generated in the 
venous end of the heart is transmitted 
through nerve axones first to the muscula- 
ture of the auricles and subsequently to 
that of the ventricles (Howell). It is be- 
yond the province of a paper of this kind 
to attempt to controvert this theory which 
still has its able advocates. It may be said, 
however, that it is possible to explain the 
various phenomena of the heartbeat accord- 
ing to the myogenic theory, which holds that 
the impulse to contraction is transmitted 
from muscle cell to muscle cell without the 
intervention of nerve cells. While it is 
admitted that there are nerves in the heart, 
they are supposed to be connected with the 
extrinsic nerves through which the rate and 
force of the heart beat are regulated. For 
although the heart muscle itself possesses 
the propertv of automatic rhythmicity, 
it is still controlled by the extrinsic nervous 
mechanism. But since the contraction 
rhvthm originates in the auricles they are 
so-to-speak the pace-maker ( Howell ) for 
the ventricles. And while it is true, as 
regards the whole-heart, that the ventricles 
derive their rhythm and rate from the auri- 



cular beat it is not to be supposed that the 
impulse from the venous end of the heart is 
essential to produce rhythmical contraction 
of the ventricles. It has been demonstrated 
that the ventricles possess an inherent 
rhythm of their own and likewise the 
auricles. In the case of the mammalian 
heart it is possible to isolate the ventricles 
experimentally from all connection with the 
auricles and even under these conditions 
with proper stimuli to set up rhythmical 
ventricular beats. 

With tiie above imperfect recital of facts 
the question but naturally presents itself as 
to the nature, character and anatomic loca- 
tion of the connection between the auricles 
and ventricles. It is only within recent 
years that this has been discovered and the 
nature of this connection has been the point 
of contention between the advocates of the 
nerve conduction and of the muscle con- 
duction theories respectively. Since His, Jr., 
in 1893, discovered a small band of muscle- 
fibres connecting- the auricular musculature 
with that of the ventricles, the myogenic 
theory of the heart beat has steadily gained 
adherents until today the majority of physi- 
ologists believe it to be the sole connection. 
Other investigators also have demonstrated 
this bundle of fibres which has been called 
the "auriculo-ventricular bundle," or the 
"bundle of His." This bundle runs from 
the middle leaflet of the tricuspid valve, 
just below the foramen ovale on the right 
side of the inter-auricular septum, passes 
downward and forward through the fibrous 
ring between the auricles and ventricles to 
blend with the musculature of the ventricles 
and terminate at the root of the aortic valve. 

It may be said also that nerve connection 
between these portions of the heart is not 
lacking, but the fact that the delay of the 
wave of contraction at the auriculo-ventri- 
cular junction is too long to conform with 
the theory of nerve conduction, while it 
does correspond with the time necessary for 
the impulse to pass through the narrow 
muscular band, is much in favor of the 
myogenic theory. This fact in connection 
with experimental evidence and clinical 
observation is sufficient ground for accept- 
ance of the latter view. After absolutely 
all nerve connection between auricles and 
ventricles has been severed experimentally, 
provided the baud of His be left intact, the 
normal sequence of auriculo-ventricular 
rhythm goes on uninterruptedly. We have 
thus proof that the path of conduction lies 
in this muscular band and this is further 
borne out by the fact that destruction of 
this path or compression of this band ab- 
solutely stops the auriculo ventricular se- 
quence. Furthermore, by experimental 
compression of the bundle of His the se- 

quence is interferred with according to the 
degree of pressure. And aside from this 
evidence, anatomic lesions of this band are 
found in cases presenting the clinical signs 
which shall presently be enumerated. 

Heart Block is then "an interference with, 
or total obstruction of, the impulse which, 
coming from the auricles, normally causes 
the ventricles to beat in regular sequence to 
the auricular contraction" (Fahlen). In 
other words, if the bundle of His is not in- 
tact the impulse cannot pass from the auri- 
cles to the ventricles, and the normal co- 
ordination is lost. Interference with the 
impulse may be partial or total: accordingly 
there results partial or complete heart block. 
Erlauger and Figerstedt experimenting on 
the mammalian heart have, by suitably 
devised clamps, produced pressure on the 
bundle of His and they were able, by vary- 
ing the degree of compression, to produce 
incomplete or complete block at will. 
Beginning with the lightest pressure and 
gradually increasing it the various stages 
of block are observed, the first effect be- 
ing an increase in the length of the auriculo- 
ventricular pause. As the pressure increases 
one ventricular beat is lost in every H), l >, 
8, 6, 5, &c, always depending on the de- 
gree of compression. Thus the various 
stages of partial block occur until finally, 
when the pressure is sufficient, there is abso- 
lute blocking of the impulse aud a state of 
complete block is observed. But it has 
already been said that the ventricles possess 
their own independent rhythmicity, so that 
when they no longer receive their pace- 
making impulse from the auricles, they 
begin their own rhythmical beat, which, 
however, is not co-ordinated with the auri- 
cular beat. Usually if the third or fourth 
auricular systole fail to stimulate the ven- 
tricle, the latter contracts spontaneously. 
And thus arises one form of arrythmia to 
which the name "relative complete block" 
(Erlanger) has been applied. There is no 
disturbance of auricular rhythm; this goes 
on unaltered and the rate may be normal or 
above, while the ventricular beat may vary 
from 10 to 40 per minute. 

Enough has been said to make clear what 
is meant by the term heart block. It only 
remains, therefore, to describe some of the 
clinical manifestations which commonly ac- 
company this condition. As long ago as 1826 
Adams, of Dublin, noted a case in which the 
jugular pulsations were greater in number 
than the radial. In 1846, Stokes, another 
Dublin physician, described this phenome- 
non more fully, and so today we speak of 
the Stokes-Adams Syndrome or, more prop- 
erly, the Adams-Stokes Syndrome, which is 
characterized clinically by ( 1 ) bradycar- 
dia, or slow arterial pulse; (2) venous pulsa- 



tioiis in the cervical veins greater in number 
than the arterial; and (3) epileptiform — re- 
sembling: petit Dial or grand mat, apoplecti- 
form, or syncopal attacks. 

The disease occurs chiefly in males after 
the age of 30. A history of syphilis is ob- 
tained in some cases; in others the history 
is doubtful; in some negative. Symptoms 
usually come on at rather advanced age, 
although there are exceptional instances 
reported of its occurrence in the young. It 
is surprising, in reading reports of cases of 
this disease, how constantly, even among 
the diversified pathological findings, some 
lesion is found in, or near the region of, the 
band of His. Even in the earlier cases this 
is true, and since it has been more definitely 
localized disease of this bundle of fibres is 
practically constantly demonstrable at au- 
topsy. While it is not practicable to review 
these reports, many cases are cited by vari- 
ous observers in which sclerotic and athero- 
matous changes of the septum, sarcomata, 
gummata, septicaemia, metastases and ne- 
crosis have been found either involving the 
band or producing pressure upon it. "All 
the chief symptoms of Adams-Stokes disease 
may be duplicated by heart block resultiug 
from a lesion in or near the bundle of His 
or by this alone. No typical case of this 
disease has been described in which heart 
block might not have been'.the trouble, and 
it can be shown that the cases of Adams- 
Stokes disease which have been studied 
with sufficiently accurate means were cases 
of heart block" (Krlanger). However, 
after all has been said, the etiology and 
pathology of this condition is not yet fully 
worked out and much remains to be done 
before heart block is understood in all its 

As mentioned above, the essential symp- 
toms are slow arterial pulse, and recurrent 
cerebral attacks. Secondary symptoms are 
digestive and respiratory disturbances and 
ocular alterations. Of the major signs 
bradycardia is most distinctive. The pulse 
rate is persistently low, varying from 40 to 
H) beats per minute; the arteries are stiff 
and the pulse full. Associated with this 
slow arterial pulse is a venous beat of nor- 
mal or very greatly increased rate. In one 
case a jugular pulsation of 140 per minute 
is reported, while at the same time the radial 
pulse varied from 10 to 30 per minute. Both 
puscultation of the praecordium and a com- 
parison of the jugular and radial or brachial 
pulsations enable one to appreciate the dif- 
ference in auricular and ventricular rates. 
On auscultation at the apex the slow not 
irregular ventricular sound is heard which 
is synchronous with the radial pulse; at the 
base is heard the faint sound of the auri- 
cular contractions synchronous with the 

pulsations of the cervical veins. 

The cerebral attacks commonly take the 
form of petit mat. However, they may be 
syncopal or apoplectiform. Usuallv they 
last from a few seconds to several minutes, 
being repeated from a few to many times in 
24 hours. Unless a close study of the car- 
diac action be made, the diagnosis of petit 
vial is usuallv made; only exceptionally are 
the seizures convulsive. Perhaps indeed 
in most cases the suggestion of petit mat is 
inevitable, since there is frequently a definite 
aura, often of the epigastric type. The face 
becomes pale and consciousness is lost 
momentarily, during which state the patient 
sometimes falls; at other times he recovers 
before equilibrium is lost. The pulse, dur- 
ing these seizures, may or may not be per- 
ceptible at the wrist. The cause of the 
attacks may be sought in the anemia of the 
brain which results from failure of the heart 
to supply a sufficient amount of blood. 

With this bare outline of facts it is neces- 
sary to omit much that is interesting. It is 
impossible to touch upon many aspects of 
the subject, especially the relation of the 
extrinsic nervous system to heart block, 
and the influence of certain drugs upon it. 
It is said that digitalis and strychnine have 
the effect of producing block in hearts pre- 
disposed to it. 

No claim to originality is made in the 
facts herewith presented. My purpose was 
to bring the subject before the society be- 
cause of its interest to myself and I do so 
with the hope that those of us who have 
opportunity will observe more closely the 
significance of the various cardiac symp- 
toms with which we are confronted in the 
routine of medical practice. The effect of 
drawing attention to the subject and of 
arousing interest in it can scarcely fail in 
the discovery of cases even in our midst. 
Especially those cases of slow pulse arising 
during the course of and following acute 
infectious diseases should be closely ob- 
served, always keeping in mind the fact 
that syncopal attacks may not arise so long 
as the recumbent posture is maintained. 

Retention of Urine and its Relic J. 

I5y Dr. Owen-Smith, Asheville, N. C. 

Retention of urine and its relief is a sub- 
ject upon which volumes might be written, 
for the field here of cause and effect is a 
broad and equally important one. The 
condition is one which at any moment may 
demand the attention and prompt action of 
any one of us; and often will tax the in- 
genuity and skill of the most alert and prac- 
ticed surgical expert. 

*Read before the Tri-State Medical Association 
meeting at Charlotte February i8, 1908. 



Retention of urine is a quite frequent 
occurrence both in surgical and general 
medical practice. It demands immediate 
and complete relief on all occasions — delay 
is hazardous — and the emergency must be 
met promptly; alleviating not only the pati- 
ent's physical distress and mental anxiety, 
but also the possibility of immediate dan- 
gers and sequelae. 

The relief is often readily effected by the 
average practitioner with the ordinary sim- 
ple methods, but the obstacles to catheteri- 
zation are often many and perplexing. 
Every surgeon appreciates the gravity of 
such cases, and man}' of us can recall by- 
gone experiences that are still painful. The 
average patient and most of the laity fail- 
ing to appreciate the difficulties, and only 
estimating the skill of the operator by the 
visible results from the first manipulations. 

We younger men have all had some sad 
experiences, and been filled with wonder 
and astonishment to see a bladder, which 
we felt at the time could not be reached by 
urethra, easily and safely emptied with the 
right catheter controlled by the gentle hand 
of an operator who clearly and definitely 
understood and appreciated the character 
and amount ol the obstruction to the urinary 

We are all better prepared nowadays to 
cope with any impediment to the urinary 
flow, for of late years more careful study 
and investigation has been directed to the 
male urethra. 

Sir Henry Thompson was the first writer 
to thresh out the kernels from the chaff, and 
with his clear and classic utterances led the 
profession out of the quagmire of vagueness 
and uncertainty and lack of specific pre- 
cision, which had so characterized the writ- 
ings upon this subject up to this time. 

Since Sir Henry Thompson's time little 
that is new or original has been written. 
However surgeons have grasped the prob- 
lem with a greater knowledge and certainty. 
So by applying his teachings and precepts 
have been able to do more work, and better 
work, and in this way by rearranging, 
extending, and adding their individual ex- 
periences have broadened the knowledge, 
giving a much wider application to the 
original principles laid down by this illus- 
trious surgeon. 

vSo I feel that if I can reflect a little from 
the greater lights so that you may perchance 
catch a ray or two which will be of help or 
interest to you I will be very glad, indeed, 
and feel that I have not taken your time 
without recompense. 

When we know the cause and degree of 
retention — having a clear and definite 
knowledge of the amount and character of 
the obstruction we will relieve all of the 

cases of acute retention: for we will make 
the proper choice of instruments and pro- 
cedures, without jeopardizing our patient 
or giving ourselves cause for uneasiness, 
certainly we will not procrastinate. 

The choice of instruments cannot be made 
at haphazard, nor the use of metallic ca- 
theters, soft, long, straight and overcurved 
or conical English or French olivary gum 
catheters be advised indiscriminately. The 
proper choice of instrument depends upon 
the due and accurate knowledge of the patho- 
logical cause of retention. 

Causes of Retention of I riue. 

The bladder may fail to empty itself from 
a number of causes, brought about by either 
an obstruction to the outflow of urine or to 
defective expulsive force. 

Obstructive causes may be mechanical, 
such as strings or ring tied around the penis, 
insertion of foreign bodies into the urethra. 
All of these may be seen in children or 
erotic freaks. Pressure from a gravid uterus 
or impacted feces. It not infrequently hap- 
pens that a calculus from the bladder be- 
comes arrested in its journey through the 
urethra, especially at its prostatic or mem- 
branous part, thereby mechanically stops 
the flow of urine. Tumors of the bladder 
or urethra may obstruct the flow in the same 
manner. Rupture of the bladder or urethra 
are also met with which give rise to reten- 
tion. The three chief obstructive causes of 
retention are: 

(1) Retention as the result of organic 
stricture of the urethra. 

(2) Retention dependent upon acute in- 
flammatory engorgement of the prostate 

(3) Retention the result of hypertrophy 
of the prostate gland (senile enlargement). 

Defective expulsive force may result from 
paralysis, atony, rupture or injury, shock, 
exhausting illnesses as long fevers, etc. 
The toxic action of drugs or the modified 
nerve action, either central or by reflex 

I will not go into the subject of retention 
from defective expulsive force at this time: 
and as all, except the last three causes given 
under the heading of obstructive causes, de- 
mand that the ordinary rules and surgical 
procedures be carried out, I will not go into 
details of symptomatology nor treatment 
Retention Produced by I 'rethral Stricture. 

Urethral stricture causing urinary reten- 
tion may be either ( 1 ) spastic stricture due 
to spasm of the musculature, usually the 
symptom of other disease processes, as in- 
flammation of the urethra, bladder or rec- 
tum, it may also be the result of psychic 
influences; (2) inflammatory strictures occur- 



ring frequently during acute gonorrhoea, 
rarely chronic gonorrhoea or chancre of the 
urethra; or any condition or inflammation 
giving rise to swelling and oedema of the 
parts involved. This condition is not infre- 
quent following operations upon the rectum 
for hemorrhoids, prolapsus ani, etc.; (3) or- 
ganic stricture is the most frequently met with 
and being of especial interest to the surgeon 
as a cause of urinary retention it will be the 
only one lo which I shall confine myself in 
this discussion. 

The term stricture is used to cover a mul- 
titude of conditions, but if limited to the 
pathological obstruction of the urethra from 
idiopathic or gonorrhoeal cause, with the 
exclusion of mechanical causes — stricture 
following trauma or surgical operation — 
retention is never absolute as the stricture 
is permeable and passable. 

I will therefore not take up the traumatic 
cicatricial strictures, etiologically speaking, 
but take the inflammatory strictures, for 
which chronic gonorrhoea is the most fre- 
quent and prolific cause. 

It is not until the inflammation invades 
Littres glands, or by following the depres- 
sions of the mucous membrane, and involves 
the submucous and cavernous tissue, with 
deep infiltration, that we have the conse- 
quent cicatrization. This process may ex- 
tend over quite a period of time and the 
symptoms preceding a urinary retention 
have been of gradual development. During 
this time there are changes in the character 
of the urinary stream; it being gradually 
reduced in diameter, becomes forked or 
spiral, perhaps twisted with a lessened 
propulsive force, and a tendency to dribble. 
As the lumen of the urethra becomes grad- 
ually more constricted, micturition becomes 
more frequent and painful. The urine is 
passed in smaller amounts; at times only 
escaping in drops or in a dribbling and in- 
significant stream, without a complete 
evacuation of the bladder being possible. 
At times catheterization becomes necessary. 
During this time the patient is not only 
wretched, but may at any time have an 
acute retention, or fall heir to innumerable 
complications and sequelae. From the dis- 
integration of the ammoniacal urine (resi- 
dual urine) or as the result of catheteriza- 
tion, cystitis is frequent. 

In young men, with rapidly forming 
strictures, we are apt to have a concentric 
hypertrophy with diminution in the size of 
the cavity of the bladder. In others with 
the frequent and intense desire and effort to 
empty the bladder we have an hypertrophy 
of the musculature and consequently a 
reticulated bladder. 

So with the retention of the urine in such 
an hypertrophied bladder we are very apt 

to have an early rupture or the format ion 
of diverticula. Also the dilatation and vesi- 
cal inflammation often extends to the ureters 
and renal pelvis, bringing on a pyelone- 
phritis anil perhaps destruction of the kidney . 
At some time, possibly without any ap- 
parent cause, or perhaps as the result of 
some trivial excess, which may be ever so 
slight in eating or drinking, or sexual irri- 
tation, exposure to cold or dampness, or 
unaccustomed exercise, something in short 
which has proven "the last straw," reten- 
tion has taken place. 

This patient applies for surgical aid, and 
while he is not as nervous and irritable as 
the man with an inflamed prostate, he de- 
pends on the skill and adroitness of his 
surgical advisor and all efforts must be 
spent at once to relieve the local trouble 
without further shock. 

As I said in the premesis there are so few, 
if any, impermeable or impassable strictures 
due to pathological causes, that when we 
attempt to relieve a urinary retention by 
the passage of a No. 8 or 10 round-pointed 
metallic or English soft catheter, and fail 
as we so often do, we must not throw up our 
hands and consider the stricture impassable. 
Nor should we mutilate the delicate mucous 
membrane with an unsuitable instrument or 
rough and continued attempts to force an 
entrance into the bladder. 

If the orifice of the stricture is- small and 
tight or eccentrically situated in the urethral 
circumference, repeated or forcible trial or 
pressure with a round-pointed instrument is 
apt to force the mucous membrane over the 
orifice without entering it. This minute 
and distorted cleft or stricture opening is so 
rammed or closed more tightly and the diffi- 
culty of detecting and entering it will thus 
be increased. 

When we are fortunate- enough to have 
an endoscope present, a fine probe or fili- 
form bougie may be passed, by sight, through 
the opening, over which the tunneled ca- 
theter of Gouley may be threaded and pass- 
ed into the bladder with the filiform to guide 
it through the opening. Even with the 
endoscope, in many cases it is impossible 
to find the opening or pass a probe through 
it, especially if the cicatrix is to one side of 
the median line, or if there are fistulas, false 
passages or diverticula present. However, 
pressure upon the bladder will often indi- 
cate the opening by a drop of urine. 

Without an endoscope, filiform bougies 
are the best and safest and most satisfactory 
instruments with which to overcome the 

It may not be remiss for me to say a word 
or two here concerning filiform bougies and 
their use. There are many different kinds 
and makes in use, some good, some bad, 



and some indifferent. The old whalebone 
filiforms, now almost, if not quite, obsolete, 
were too stiff, often rough and so brittle as 
to snap in two in the urethra. They were 
also not sterile and could not be made so. 
1 have found the fine French bougies to 
give me the greatest satisfaction; however 
any make will do so long as the filiform is 
the proper length < 12 to 15 in.), elastic yet 
sufficiently resistant, not rigid nor sharp 
pointed, and capable of standing repeated 
sterilization. The majority should be 
straight, but a few with elbowed or slightly 
angled extremities will be found useful in 
some cases They should be from about 
1 2 to 15 inches in length and approximately 
l-.^nd of an inch in diameter, or of a 
diameter corresponding to the tunnel of the 
smallest Gouley catheter. 

The introduction of filiform bougies re- 
quires the greatest care and patience, and 
needless to say asepsis. Local anesthesia 
may be used but is rarely needed in these 
cases. The meatus and urethra should be 
thoroughly cleansed and then filled with 
sterile oil. With a slight rotary motion 
and gently pulling on the penis pass the 
filiform down to the stricture. Don't be 
deceived if the filiform should engage in a 
urethral follicle or impinge in the mucous 
membrane. When the stricture is reached, 
rotate the shank or upper end of the filiform 
between the thumb and fingers, at the same 
time gently pushing it forward. 

If you are so fortunate as to enter the 
stricture orifice, well and good, but such is 
not often the case. If the point does not so 
engage, leave the filiform in place, and im- 
mediately pass down another one with the 
same manoeuver; and if necessary a third, 
fourth, and perhaps a fifth, sixth or seventh, 
"like a bundle of arrows in a quiver." 
Then while the bundle is held firmly, each 
filiform is tried separately, when nearly 
al\v;iys one of the number will enter the 
stricture orifice. Not succeeding with all 
straight bougies, as may be the case, use 
one or two with an elbowed or slightly 
angled extremity. 

If after a patient effort has been made 
with each one of the filiforms, the opening- 
is not detected, the stricture is probably 
directed to the right and away from the 
surgeon. So bearing in mind that an oper- 
ator instinctively, as well as involuntarily, 
works toward himself, change your position 
to the right side of the patient, withdraw 
the bundle of filiforms an inch or so and 
repeat the manoeuver with each bougie, and 
success will usually be attained. 

The filiform having passed through the 
stricture opening into the bladder a tunnel- 
ed (iouley catheter is threaded over it and 
passed down to the stricture, but don't try 

to push the (iouley through the opening 
while holding the filiform and making the 
catheter slide along it. Withdraw the fili- 
form from a half to one inch from the blad- 
der and then holding the filiform and ca- 
theter firmly together push them gently on, 
maintaining unchanged this relative posi- 
tion of both instruments. The catheter will 
thus engage the opening and pass on into 
the bladder. 

1 have found in some instances, where it 
was impossible to pass a metallic (iouley 
catheter, that an ordinary small, (9 or 10 F.) 
straight, and flexible catheter threaded over 
the filiform, used in the same way as the 
metallic, would pass the stricture. 

In a few extreme cases it will be found 
impossible to pass any catheter over the 
bougie through the stricture. In such a 
case the urine will often escape along the 
filiform by capillary action and relieve a 
distended bladder in the course of an hour 
or two. This will furnish temporary relief 
and permit us to prepare for the more radi- 
cal and permanently beneficial procedure. 

Where it is not the part of discretion — or 
circumstances forbid — to proceed with the 
restoration of the urethral canal, and be- 
cause of extreme tightness or irritation of 
the stricture, we anticipate a recurrence of 
the retention, it is wise to withdraw the fili- 
form enough to avoid irritation of the sensi- 
tive membrane of the vesical triangle and 
leave it tied in situ until more permanent 
relief can be secured and assured. 

Following an attack of retention from 
organic stricture we have learned from clin- 
ical experience that with the proper seda- 
tive, hygienic, and dietetic treatment, recur- 
rence is not often encountered and the re- 
tention does not take place again for some 

I cannot pass on, however, without re- 
minding you of the prophylactic treatment 
here and urging that these strictures be 
properly treated with the restoration of the 
urethral calibre before retention has taken 

Perineal section and the complete removal 
of the cicatrix will give the greatest degree 
of comfort and absence of anxiety to both 
patient and surgeon. 

In complete retention, when all efforts as 
mentioned above or at hand have failed to 
relieve, a suprapubic cystotomy is the oper- 
ation of choice and will afford time and 
preparation for a complete removal of the 

Retention of I r rine Produced by Acute Inflam- 
matory Engorgement of the Prostate 

Acute prostatitis rarely occurs as a prim- 
ary inflammation, but usually occurs as an 



extension or contiguity of neighboring 
organs: most frequently the urethra, less 
often the bladder. 

The indiscriminate use of injections and 
instruments during an acute urethritis, or 
following an imperfectly cured gonorrhoea, 
are responsible for the infection and inflam- 
mation of the prostate in the majority of 
cases. Traumatism, violent and prolonged 
exercise, particularly on horseback, may 
give rise to an acute inflammation of the 
gland. Any one of these causes may bring 
about a rapid and marked vascular conges- 
tion of the whole gland, or perhaps one or 
more of its lobes. The lateral lobes are 
most frequently inflamed, and rarely one 
without the other. 

This engorgement often so compresses 
the prostatic urethra as to greatly interfere 
with the flow of urine or complete retention 
may be brought about. 

The inflamed prostate gives rise to severe 
pain in the gland, throughout the length of 
the urethra, and especially in the head of 
the penis. The pubic and perineal regions 
are tender, as is also the gland and sur- 
rounding tissue upon rectal examination. 

When retention takes place the constitu- 
tional symptoms are marked. The pulse is 
rapid and often wiry, there is high fever, 
and while the face is flushed the forehead 
is usually covered with sweat. The irrit- 
ability and disquiet of the patient increases 
with the distention of the bladder. In his 
violent efforts to void urine or increase the 
capacity of his bladder by change of posi- 
tion he can't keep still and often is demor- 
alized and dances about the room. He 
thus runs great risk of rupture or of atony 
from overstretching of the muscular fibres 
of the bladder wall. 

Relief must be forthcoming, the bladder 
reached and the retention relieved, if possi- 
ble, on the first and single trial. Prompt 
relief must not be limited by palliative pro- 
crastination, as in days gone by, when 
warm baths, hot applications and opiates 
were resorted to with the idea of relaxing 
the so-called "spasm." 

Anesthesia and a happier instrumentation 
have saved many a poor sufferer from being 
tortured in these latter days. 

Make the first attempt to catheterize with- 
out an anesthetic, but very often the condi- 
tion of the patient, as outlined above, will 
almost, if not quite, prohibit any instru- 
mentation without an anesthetic. 

The retention here it will be remembered 
is due to compression of the urethra by the 
swollen and tender gland substance. The 
caliber of the urethra is not organically 
lessened, its mucous surfaces are simply 
pressed together. 

Possibly the length of the prostatic urethra 

is temporarily increased and rendered tor- 
tuous by the tension of the full and dis- 
tended bladder. 

To traverse such a canal, the catheter 
should be so soft as not to bruise the tender 
and swollen mass; and to do this it should 
possess a flexible lower extremity two or 
two and a half inches in length. The upper 
five-sixth of the shank or handle should be 
stiff or firm. In the majority of cases the 
elbowed flexible catheter of Mercier can be 
readily passed. Failing to pass this catheter 
the straight soft rubber catheter of Nelatou, 
with the ordinary stylet to maintain the 
rigidity and form needed, should be tried. 
This can be bent, and several different 
curves made possible with the same instru- 

I would discourage even an attempt, be 
it ever so gentle and conservative, with the 
prostatic silver or metallic catheter, as well 
as the ones of block tin. The silver catheter 
has too pointed an extremity and the im- 
proper curve unfits it for common use. The 
malleable tin catheter can be bent to meet 
the demands of a very devious entrance to 
the bladder, but if used at all, it must be 
with the most infinite care and gentleness, 
appreciating all the while that it is bending 
in the urethra and is exceedingly liable to 

The long-curved tunnelled catheter stiff- 
ened by a whale-bone guide may solve the 
difficulty in some cases. 

Let me impress you with the fact again 
that the time for these manipulations is 
limited and that the dangers from immoder- 
ate, careless or unwise demonstration is never 
to be underestimated. 

By employing either the Mercier or Nela- 
tou catheter, stiffened as mentioned above, 
especially the elbowed Mercier, and with 
the patient In the proper position 1 dorsal ) 
most of these cases will be catheterized at 
the first trial with very little delay or dis- 

The catheter, if a Mercier, should be 
pushed gently down with the projection of 
its beak presenting upward until the swollen 
gland or obstruction is reached. Here a 
soft, boggy resistance, sometimes more than 
an inch in length, will be found and a cer- 
tain amount of pressure, not force, will be 
necessary to traverse the obstruction and 
reach the distended bladder. 

The distressing symptoms almost imme- 
diately abate as soon as the accumulated 
urine is withdrawn. The inflammatory en- 
gorgement of the prostate does not diminish 
so rapidly, and in some cases, especially 
where great difficulty has been met with in 
passing the catheter, it may be wise to leave 
the catheter tied in situ for at least twenty- 
four hours. This form of retention rarely 



occurs or redevelops, especially if the excit- 
ing cause is relieved and is not renewed. 

If the over-disteution of the bladder has 
lasted for any length of time, so that the 
muscular fibres have been greatly stretched, 
a temporary atony, or loss of contractility 
may ensue. With this loss of power by the 
bladder to empty itself, the reaccurnulation 
and retention of the urine will demand sur- 
gical aid and catheterization again. All 
cases, therefore, of this retention should be 
carefully watched and catheterized at regu- 
lar intervals until normal urination is estab- 

Retention from Prostatic Hypertrophy, (Sen- 
ile Enlargement. 

The most important pathological change 
of the prostate is hypertrophy, and this con- 
dition is, in a great number of cases, sooner 
or later the cause of retention of the urine. 

The form of hypertrophy depends upon 
the amount of hyperplasia taking place, to 
a certain extent, in the glandular or mus- 
cular part of the gland substance. This 
distinction must be made in the early stages, 
for later both parts are involved to a greater 
or less degree in all cases. 

The hypertrophy may involve all three 
lobes, or only one, perhaps two. The mid- 
dle lobe is less frequently involved than 
either of the lateral lobes, but usually the 
whole gland or all three lobes are affected 
simultaneously. If the middle lobe is in- 
volved it is of the muscular type, being less 
rich in glandular elements, and is spread 
out and broader than usual, but may be 
elevated or pedicled. Such a lobe may ex- 
tend into the bladder and act as a valve to 
obstruct the urethral orifice, especially when 
the bladder is full and contracts down 
firmly, thus giving rise to retention of the 

Whenever the prostrate is enlarged the 
prostatic urethra will be pressed upon from 
one or both sides and necessarily becomes 
altered in length and caliber. These in- 
fluences may so variously combine as to 
distort, elongate, curve, produce an angle 
or render it tortuous, and the urine will be 
impeded and perhaps inhibited. Under 
these conditions the prostatic urethra may 
be increased to two inches in length. 

The opening of the urethra is pushed 
forward and upward, thereby producing a 
pouch of bladder behind the enlarged pros- 

When the lateral lobes are hypertrophied 
the urethra is compressed from side to side 
and elongated . 1 f the middle lobe is hyper- 
trophied the urethra is bent forward at an 
acute angle, leaving a recess so formed, 
which makes the passage of a catheter ex- 
tremely difficult. It will be seen that a 

catheter entering the bladder under these 
conditions must do so by following one of 
the grooves into which the urethra has been 
divided by the middle lobe. It will also be 
seen readily from the above that the lateral 
and posterior walls of the urethra are alter- 
ed, leaving the anterior wall more or less 
unaltered or affected. So without hesita- 
tion we will select an instrument, for enter- 
ing the bladder, so constructed that the 
beak will be guided along the anterior wall. 

The internal sphincter is so often involv- 
ed in this hypertrophied prostate that it 
cannot be recognized as a well marked ring. 
The internal orifice often being a swollen 
ring in which there is no trace of a sphinc- 
ter; the hypertrophied prostatic tissue lying 
just under the thickened mucous membrane. 
Some remnants of the sphincter may remain 
in the posterior commissure and serve to 
join the lateral lobes, and thereby form the 
"muscular barrier" so often encountered 
and heard of. This barrier is the cause of 
so much difficulty in passing an instrument 
in some cases. Also when the urethra is 
curved abnormally forward this is the seat 
of many false passages where unskilled, 
unnecessary, and rough instrumentation is 
persisted in. 

The urinary passages (as well as the kid- 
neys in some instances ) all suffer from this 
interference with urination. The evacua- 
tion of the bladder is imperfect; this leads 
to eccentric hypertrophy; diverticula are 
formed; the muscular fibres of the bladder 
wall lose their tone and relaxation /takes 
place. The bladder is no longer able to 
empty itself. The residual urine becomes 
ammouiacal and by its irritation sets up a 
cystitis, which inflammation may in turn 
extend to the ureters and perhaps the kid- 
neys. Frequent catheterization by itself or 
in addition to the mechanical obstruction 
will produce cystitis, ureteritis, pyonephro- 
sis and nephritis, with complete retention 
of urine occurring at any time or anywhere 
along this march of events. 

Sudden obstruction may be the result of 
an acute congestion of the dilated and vari- 
cose veins, which are so often combined 
with hypertrophy of the prostate, causing 
the gland to temporarily greatly increase in 

The symptom complex of hypertrophy of 
the prostate is familiar to all, but in rare 
instances the first intimation of this trouble 
may be an acute retention of the urine. 
This may follow some trivial indiscretion 
in eating, drinking, exposure to cold or 
dampness, or the too long voluntary reten- 
tion of the urine; all of which may have 
been indulged in before without this com- 
plication or result. 

Bear in mind that the obstruction to be 



overcome is the pressure of the swollen 
lateral lobes, and the upward and perhaps 
irregular projection of the middle lobe of 
the gland. Tire urethra is still in place, 
but tortuous and elongated. 

The instrument required is not a metallic 
instrument, but one with a soft and pliant 
extremity. A metallic instrument is very 
likely to produce a false passage, or at best 
irritate and perhaps rupture the mucous 
membrane, predisposing infection. Metallic 
instruments of all kinds and curves, for 
this use, are rapidly being discarded and 
thrown into the junk pile where they belong. 

The Xelaton catheter, so stiffened as to 
give a firm shank, leaving a flexible point, 
will answer admirably when the middle 
lobe is not prominent. In this case, for the 
projection of the middle lobe, an upturned 
tip, in fact the elbowed catheter of Mercier 
(angle 110) guided by a gentle and intelli- 
gent hand, with possibly a finger in the 
rectum to assist, will be found to enter the 
bladder easily and comfortably. 

By placing a ?\Iercier catheter in hot 
water we may bend it to any desired curve, 
and in this way it will be found to follow a 
tortuous urethra, and with the elbowed tip 
will easily ride over the projecting middle 

Hey's method will often be found to give 
a happy result. 

Do not subject the patient to prolonged, 
perhaps strenuous, and unsuccessful attempts 
to introduce any catheter. 

If you are not prepared to expose and 
open the bladder supra-pubicly, or perineal 
or a complete prostatectomy, then supra- 
pubic aspiration may be resorted to and 
immediate relief afforded. Aspiration gives 
speedy relief and may be used in an emer- 
gency, but in the majority of cases the 
altered condition of the urine and the blad- 
der walls are strong contraindications. 

False passages are inexcusable, either the 
proper instrument has not been chosen, or 
the hand that controlled it was not gentle 
and the operator did not have a clear and 
definite idea of the character and amount 
of the obstruction, all of which are essential 
and can be gained by a little patient and 
intelligent work. 

The many reasons for scrupulous asepsis 
in dealing with all these conditions and 
with all catheters, are so very evident to 
every one that I will refrain from all but 
mentioning the subject. 

When a bladder has been over-distended, 
as is the case in all retentions, it should be 
emptied very si >wly, and in most cases a 
small amount of urine should be left in the 
bladder. Rapid evacuation is followed very 
often by congestion and perhaps hemorr- 
hage. Also the ureters have possibly been 

dilated with the pelvis of the kidney, and 
even the capsule of the kidney stripped off; 
if this positive pressure, produced by the 
retention, is made a negative pressure 
rapidly, then anuria is inevitable. 

A Drugless Clinic* 

By E. H. Martin, M. D., Hot Springs, Arkansas. 

The title of this paper may suggest that 
1 have abandoned the use of material medi- 
caments and have been experimenting with 
some occult force or have been trusting to 
suggestion or mental healing. Let me has- 
ten to correct such an impression. My 
drugless clinic consisted in recording the 
progress of a number of cases who have 
been taking the baths at Hot Springs with- 
out any medical treatment to reinforce their 
curative effects. 

I read papers in April and May before 
the Mississippi and Louisiana State Medical 
Associations on the physiological effects of 
the waters of the Hot Springs of Arkansas. 
In making the experiments and investiga- 
tions on which these papers were based I 
was struck with the further importance of 
investigating the therapeutic effects of these 
baths. Also with the impossibility of cor- 
rectly judging the therapeutic effects of the 
baths on patients under medical treatment. 
And as a matter of course no physician 
could experiment upon private patients. 
That might be done by the family physician 
at home but not by a temporary medical 
advisor at a health resort. Our private 
patients being away from home and at con- 
siderable expense generally preface an ex- 
amination by stating that they can only 
stay at Hot Springs for a limited time and 
demand everything possible to secure the 
greatest degree of benefit that can be ob- 
tained during a few weeks. 

There being no way in which the thera- 
peutic effect of the baths, unaided by medi- 
cines, could be observed in the regular course 
of practice I turned to the Government Free 
Bath House where a large proportion of the 
bathers not only have no medical advice 
but have no money with which to buy medi- 
cines and are forced to rely on the effects of 
the baths alone to give them relief. 

These poor people go to Hot Springs with 
barely enough, and in many cases insuffic- 
ient, means to procure food and shelter. 
There they live from hand to mouth, badly 
quartered, frequently poorly fed, depending 
upon charity, odd jobs or uncertain remit- 
tances from home for the actual necessities 
of life, and many of them do not consult a 
physician because, while medical advice 

"Read before the Tri-State Medical Association of 
Mississippi, Arkansas and Tennessee, Nov. 20, '07. 



may be obtained free of cost, it would do 
tlieni no good without the means of having 
their prescriptions fdled. 

It struck me that if the baths save any 
useful therapeutic effects against such odds 
of lack of nourishment and poor living that 
such effects must be very genuine. I found 
that over 150,000 baths are given to nearly 
5000 indigent sick annually, an average of 
over 400 bathing at this one bath house 
every day. The Government reported 93 
per cent, as benefited and over 18 per cent. 
as "rmrd" but kept no separate records of 
those depending on the baths alone and 
those also taking medical treatment. 

So I made application to the Interior 
Department for permission to make special 
examination of bathers at the Free Bath 
Mouse for the purpose of making clinical 
records, such examinations to be with the 
permission of the person examined. This 
was granted after mouths of waiting, and 
not until July was I able to commence these 
observations, the recording of which consti- 
tutes my drugless clinic. 1 could only give 
the hour from 8 to 9 a. m. to this purpose, 
and as the bathers are coming and going 
all day I had to be satisfied with those 
whom I could see at that hour. Many were 
taking medicines prescribed by friends, pre- 
scribed over counters, patent medicines, 
remedies brought from home, and a few 
had regular medical advice. Xone of these 
interested me and I only kept records of 
those who were taking no drugs wdiatever, 
excepting purgatives when actually needed, 
the baths having a tendency to constipate 
most patients. These patients further agreed 
in every instance to notify me if at any time 
they began taking medicine, so that I might 
file their histories away as abandoned. This 
accounts for many of those whom I class 
under "Insufficient Report" in the follow- 
ing lists. 1 give below a list of the first one 
hundred consecutive cases recorded in this 
drugless clinic. Of these, 35 will have to 
be excluded under the head of insufficient 
report to form judgment. ( )f the remaining 
65 cases there were 9 recoveries, 17 greatly 
improved, 8 much improved, 23 improved 
and S unchanged, all without a dose of 
medicine. ( >f the 17 classed as "greatly 
improved" some cases are still under obser- 
vation and will probably result in recoveries, 
clinically speaking. The 100 cases were as 

Xon-svphilitie ulcers of leg 3 

Acne.! 2 

Nasal catarrh 2 

Hemiplegia, * 2 

Locomotor ataxia, 1 

Dermatitis, 1 

Morphinism, 1 

Bright's Disease 1 

Hysteria 1 

Gall bladder disease, 1 

Cystitis, non- venereal, 1 

Syphilophobia, 1 

No diagnosis made 1 

ion " 

Of the 38 cases called rheumatism 16 
were classed as chronic, and these were the 

Recovered, 1 Cases. 

Greatly improved, 3 

Much improved, 1 

Improved 2 

No change, 3 

Insufficient report, 6 " 


Eight cases were classed as subacute 
rheumatism and fared thus: 

Recovered, i Cases. 

Greatly improved, 1 

Improved > 

Insufficient report 1 

The gonorrhoea] rheumatism numbered 
an unlucky 13: 

Recovered, 1 Cases. 

Greatly improved 2 

Much improved 1 

Improved, 3 

Insufficient report 6 


There was one case of muscular rheuma- 
tism which 1 was unable to classify as to 
etiology, insufficient report. 

The 25 cases of syphilis were 16 in the 
secondary stage, 8 in the tertiary and 1 
hereditary. The 16 in the secondary stage 
gave these results: 

Greatly improved, (> Cases. 

Much improved 1 

Insufficient report, * ( -> 

Various forms < 
Different stages 

if rheumatism,., 
of syphilis, 

. . 38 Cases, 
.. 25 




. 4 

Neurasthenia, .. 


... 3 " 


'•'Nearly all l ) began inunctions. 

The 6 cases of tertiary syphilis were as 

Greatly improved 1 Cases. 

Much improved, 2 " 



Improved, - 

No change, 1 

Insufficient report, 3 


The one case of hereditary syphilis im- 

The five cases of neuritis resulted in: 

Recovered 1 Cases. 

Greatly improved, 1 

Much improved, 1 

Improved , 1 

No change 1 


The four cases of malaria gave: 

Recovered, 1 Cases. 

Greatly Improved, 1 

1 mproved 2 


The four cases of gonorrhoea resulted as 

No change 1 Cases. 

Insufficient report,* 3 

* Began medical treatment. 

The three cases of neurasthenic were all 

Greatly improved, 1 Cases. 

Improved 2 

The three cases of chancroid: 

Improved, 1 Cases. 

Insufficient report,* 2 

;,: Began local treatment. 

The three cases of leg ulcer, non-syphil- 

Recovered, 1 Cases. 

Improved, 1 

Insufficient report, 1 

Of the two cases of acne one showed 
slight improvement and one gave insuffic- 
ient report. 

The two cases of nasal catarrh (non- 
specific) were, strange to say, both much 

Of the two cases of hemiplegia one case 
resulted in recovery after 52 baths. This 
case was of 10 months standing and the re- 
covery was probably a natural event. ■ But 
the recovery was very complete. The other 
case of three years standing was greatly 

The case of locomotor ataxia (without 

syphilitic history) was much improved, 
whether incidentally or not I can only 

The case of dermatitis was greatly im- 

The case of morphinism was much im- 
proved in general health and the daily use 
of the drug had been reduced to a minimum 
when the case was lost sight of. 

The most remarkable result was show:; in 
the case of chronic nephritis which after 21) 
baths became clinically well; declared him- 
self well and left for home without giving 
me an opportunity to make a final examin- 
ation of his urine. Cardiac compensation 
had resulted and the shortness of breathing 
and all oedema had disappeared. 

The case of hysteria was much improved 
after only 6 baths. I will not claim credit 
for the baths for this. 

The gall bladder case made no change 
and went home by my advice for surgical 

The cystitis case was slightly improved; 
later failed to report. 

The man with syphilophobia, a state of 
mind frequently seen at Hot Springs, was 
only under observation a short time when, 
in spite of having been assured by others 
as well as me that he had no syphilis, he 
began rubbing "Sixes." These cases of 
uneasy conscience are far more troublesome 
than a dozen cases of real syphilis. They 
go from one physician to another, never 
satisfied with an assurance that they have 
not syphilis, until finally they fall into un- 
scrupulous hands and are put upon anti- 
syphilitic treatment for the sake of a fee. 

I was recently consulted by two patients, 
man and wife, who had come 700 miles for 
antisyphilitic treatment and Hot Springs 
baths. The man told me that a year ago 
he had been away from home and wife for 
a month and during that time had for the 
first time in his life had illicit sexual inter- 
course. A week later he was awakened in 
the night with a violent cramping in his 
bowels and a diarrhoea, no venereal symp- 
tom but he thought he had caught some- 
thing. With a heavy heart he went home 
and naturally an intercourse with his wife 
followed. One week later his wife awoke 
in the night with a violent cramping in her 
abdomen followed by a diarrhoea. Then 
he was positive that he had some terrible 
"blood disease" and had given it to his 
wife. I can convince that man that he has 
not syphilis, in fact I do convince him of 
the fact nearly every day, but he conies 
back the next day just as much worried 
and unconvinced as ever. Such cases of 
guilty conscience taking the form of syphilo- 
phobia are frequently seen at Hot Springs. 
With apologies for the above digression 

l l >4 


I will return to my drugless clinic. 

The results which I have given in the 
above analysis of LOO cases must be consid- 
ered with due regard to the social condition 
of the patients, to their lack of proper nour- 
ishment in many cases, to unsanitary en- 
vironment and to the short time during 
which many of them were under observa- 
tion. When so considered the results will 
compare very favorably with those in an 
equal number of cases under the best medi- 
cal treatment. Understand, I am not be- 
littling medical treatment, quite to the con- 
traty, many of those cases classed under 
the head of "insufficient report" were so 
classed because I had, out of pity for the 
time being lost and suffering prolonged, 
advised and urged, and frequently provided 
means for, medical treatment. 

And now we come to a consideration of 
how these baths alone could have accom- 
plished such results. This brings us back 
to the physiological effects in explanation 
of the therapeutic effects. I will quote 
liberally from the papers before mentioned. 

1. For the sake of comparison, I first 
called attention in those papers to the fact 
that ordinary water, no matter how hot, 
will cause no rise of temperature in a healthy 
subject immersed therein — the thermolytic 
centers guarding against any increase of 
temperature from conducted heat. 

2. I next called attention to the remark- 
able phenomenon observed when any per- 
son is immersed in a bath of Hot Springs 
water at a temperature even lower than that 
of the bod> — the subject "s temperature ris- 
ing very promptly in a few minutes to 101, 
102, 103, and even to 105 degs., Parenheit. 
if kept in the bath very long, the pulse in- 
creasing in rapidity correspondingly. 

3. 1 explained this rise of pulse and tem- 
perature by the very evident increase in 
metabolism and combustion in the cells of 
the patient's bod\ — this increase in cell 
activity being the source of good or evil 
peculiar to the Hot Springs bath. 

4. I offered a simple method of dosing 
this increased metabolism and keeping it 
within the bounds of good for any particu- 
lar case by the use of the clinical ther- 
mometer. First judging from an examina- 
tion of the patient how great a reaction 
would be desirable, 1 direct him to be re- 
moved from the tub when his sub lingual 
temperature reaches that point. 

.S. The after effects of this increased me- 
tabolism were classified as eliminative and 
constructive, the elimination of the products 
of combustion and other poisons being evi- 
dently through skin, kidneys and liver, and 
the constructive effect being due to an in- 
crease in cell activity in the hematopoietic 

6. In explanation of these remarkable 
and peculiar effects, produced by no other 
water and in like degree by no other agency, 
to my knowledge, I offered as a working 
theory the radio-activity of these waters. 
The links in the chain are the facts that an 
exposure to the X-ray increases metabolism, 
that the radium ray simulates in every im- 
portant effect the X-ray, that radio-active 
substances have the same effect, to a certain 
degree, as the salts of radium, and that 
these waters have been proven by experts 
employed by the Government to be radio- 

7. Attention was called to and stress laid 
upon the fact that these are not merely hot 
baths, that none of the effects obtained de- 
pend upon the temperature of the water, 
that the water being naturally hot is merely 
incidental, and that the same effects are 
observed if the bath is given at 94, 96, 98, 
or 100 degrees, in fact that the bath may as 
well be prescribed "comfortable" as to be 
given at any given temperature as far as 
the "Hot Springs effect" is concerned. 

In addition to and as a support to these 
observations and deductions it is very evi- 
dent that exhaustive experimentation should 
be made on the following lines: 

1. To test elimination, it should be de- 
termined before the subject takes the baths, 
using perfectly healthy subjects to get the 
true physiological effect, the total solids 
eliminated by the kidneys within 24 hours; 
this to be done on several subjects and on 
several successive days. Then these sub- 
jects should be given the baths and the total 
urinary solids determined each day; also an 
estimate should be made by weighing the 
subject before and after the sweat, of the 

.solids eliminated through the skin, (the 
specific gravity of the sweat to be used in 
making this estimate), and added to the 
total urinary solids eliminated. This has 
not been done and can not be done without 
great expense, as healthy subjects would 
have to be employed. The Government, 
as it owns the Springs, should send Dr. 
Wylie and his "poison squad" to Arkansas 
for that purpose. 

2. To test the constructive effect of the 
increased cell activity of the hematopoietic 
system anemic subjects should be used and 
a hemoglobin percentage and a white and 
red blood cell count made before beginning 
the baths and again after every few baths, 
say once a week. In the meantime a regu- 
lar diet should be observed and no medicines 
given which affect the hemoglobin percent- 
age or the blood cell count. 

Manifestly this is impossible in private 

3. The remaining obvious experiment 
needed is fortunately within reach of the 



individual observer, that of the effect of the 
bath on the blood pressure. As is well 
known, any warm bath will have the effect 
of slightly reducing the blood pressure. 
But, with this bath causing an apparently 
sthenic fever accompanied by a pulse 
greatly increased in rapidity, one would 
naturally expect an increase in blood pres- 
sure. The contrary is the case, and in a 
series of experiments, which I have made 
at the tub-side, not all, however, on sub- 
jects in perfect health, the blood pressure 
fell from 5 to 50 millimetres of mercury for 
a two or three degree rise in temperature. 
This seemed very puzzling at first, but on 
consideration of the report of different pati- 
ents, who had accidentally stayed too long- 
in the tub and whose temperatures had gone 
to 104 and even over 105, the explanation 
at least seemed apparent. These subjects 
report symptoms not attributable to full 
arteries but to over-full veins, and 1 have 
no doubt that many of the cases of syncope, 
occurring in the bath houses, which are 
blamed on the heart are really due to cere- 
bral anemia from the disproportionate 
amount of blood in the superficial veins. 

As a matter of course, if the blood pres- 
sure in the venous system is increased, the 
blood pressure of the arterial system, as 
taken by the sphygmomanometer, is dimin- 

With this knowledge that the baths do 
increase metabolism, that there is probably 
increased cell activity in diseased tissue as 
well as in healthy tissue, that absorption of 
exudates must be thereby promoted and 
that elimination of waste products is in- 
creased, that reconstruction of healthy tissue 
is accelerated, that more blood is made and 
more food assimilated, it is not surprising 
that certain classes of patients are benefited. 

It will sound trite for me to call attention 
to the functions played by cell activity in 
life, to the fact that cell activity is life; 
normal cell activity is health, an increase 
above normal in the activity of the cellular 
elements of an organ generally means in- 
flammation, a decrease below normal means 
chronic disease of some kind, and a cessa- 
tion of cell activity means death. 

So we see these baths forbidden in all 
cases of active inflammation and wheuevel 
the temperature of the subject is above 
normal. And it is natural to expect benefit 
from them in cases of chronic disease with 
lowered cell action and sub-normal tem- 

In no disease is a sub-normal temperature 
so constantly seen, especially of mornings, 
as in the various conditions classed as 
rheumatism, so it is not surprising that we 
find that 38 per cent, of these 100 patients 
were of that class. Twenty-five per cent. 

were syphilitic, and this proportion seems 
justified when we consider that to increase 
metabolism and vitality must mean to raise 
the opsonic index. 

The malarial cases are a very small per- 
centage of this series because malaria sel- 
dom drives the poor to health resorts, but 
in private practice we find a much larger 
percentage of malaria poisoned patients 
taking the baths and the benefit to them 
was a surprise to me as a swamp doctor, 
but the increasen activity of the blood mak- 
ing apparatus explains the prompt benefit 
to these cases. 

The lowered blood pressure explains the 
probable modus of relief in neurasthenia 
and in many chronic diseases having aricrio- 
sclerosis as a cause. 

It is not my purpose in this paper to go 
exhaustively into the physiological effects 
or therapeutic uses of the Hot Springs baths, 
such points of these subjects as I have 
touched on being called forth by way of 
commentary on the results observed in my 
drugless clinic. 

412 416 Dugau-Stuart Hldg. 

The Iodine Treatment of Puerperal 
Sepsis, i 

By Chas. R. Robins, M.D., Richmond, Va., Pro- 
fessor of Gynecology Medical College of \'a , 
Gynecologist Memorial Hospital. 

It is not the intention of this paper to 
deal with the history, etiology and pathology 
of puerperal sepsis except incidentally. The 
principles governing these points have been 
thoroughly studied and amply proven, so 
much so that it would be a waste of time to 
discuss them at this meeting. 

It is now universally conceded that puer- 
peral sepsis is a wound infection in which 
various organisms may participate, but in 
which the difference in the disease is more 
or less that of a difference in severity. The 
attempts to isolate specific organisms from 
examinations of discharges has been to a 
great extent disappointing and not pro- 
ductive of any good, so that the classifica- 
tions on bacteriological findings at the pres- 
ent time may be regarded as unsatisfactory. 

Clinically we recognize two more or less 
distinct types, one in which there is a foul 
smelling discharge, and the other in which 
there is practically no discharge. The first 
is usually due to an imperfect evacuation 
of the uterus, and the second to a direct in- 
fection in which the streptococcus is sup- 
posed to be the leading factor and is a con- 
dition of septicaemia from the beginning. 
These two types are to a certain extent dis- 
tinct, but so frequently merge that it is 

i Read before the Tri-State Medical Association 
meeting at Charlotte February [8, 1908. 


hardly safe to base our line of treatment on point to which I wish to call attention is 

a differentiation. that in infections, involution of the uterus 

I believe that to a certain extent harm is invariably arrested and on examination 
has resulted from so great an emphasis be- instead of finding the firm and well con- 
ing placed on the fact that infection is tracted uterus of a normal puerperium, the 
usually due to either the physician or the uterus is several times this size and is soft 
nurse, so that a doctor feels that for him to and boggy. 

acknowledge that he had such a case would The next point to which I wish to call 
be to incriminate himself. There is no attention is that whatever may be the tilti- 
doubt that a great good has been accom- mate termination of the disease, the primary 
plished by this line of teaching, so much so seat is in the uterus or lower genital tract, 
that every physician undertaking a case of In other words there is a stage in every case 
obstetrics feels it incumbent upon himself where the disease is local and may be treat- 
to eliminate every possible means of infec- ed by local measures. This is the most 
tion. Unfortunately, however, notwith- important point, and is especially to be con- 
standing these extreme precautions it oc- sidered because so many of the modern text 
casionally happens that sepsis does develop, books attempt to teach a sharp differentia- 
The explanation of this is that there are so tion in the varieties of infection, in some of 
many factors over which the physician does which local interference is advised and in 
not have absolute control that notwithstand- others prohibited. The proposition that is 
ing the greatest care on his part infection presented to you herewith is that they are 
may develop. We venture to say that there all primarily local and there is a time when 
are few physicians of extensive experience they can be cured by local measures, 
who have not had a case of infection. In The method which I wish to advocate is 
hospitals where the patient is absolutely not one for which I wish to claim originality, 
under the control and care of the physician It was ably set forth in an article by Dr. I), 
and his orders are thoroughly and intelli- J. Coleman, Professor of Obstetrics in the 
gently carried out, it is possible to make Medical College of Virginia, which appeared 
puerperal sepsis an impossibility, but in in the Old Dominion Journal, of February, 
private practice such a condition is extreme- 1904. It is, however, a method which I 
lv difficult to obtain. have employed with most gratifying results 

My object in calling attention to this for some years, and is as follows: The 
phase of the question is to encourage those patient is brought to the edge of the bed 
who have the boldness and honesty to admit and the limbs properly supported. The an- 
when they have a case of puerperal sepsis, terior lip of the cervix is seized with a pair 
because I believe that success in treatment of volsellum forceps and the cervix brought 
must depend on a prompt diagnosis and the down to the ostium vaginae. The cavity is 
early application of the proper treatment, then explored with a dull curette and em- 
All of us are familiar with those cases which bryotomy forceps. This should be done in 
are recited, in which the patient develops a every case without reference to our previous 
fever after a confinement, which runs a conception of the completeness of the uter- 
prolonged course and results in either death ine evacuation. Almost invariably some- 
or impaired health, in which the diagnosis thing will be brought out, but it does not 
is made of malaria or some other extra- follow by any means that the discovery of 
genital malady, and in which death is retained fragments reduces the case to one 
ascribed to heart failure or uremia or some of sapremia. The presence of this foreign 
other of the end results of a profound infec- matter acts as a nidus for bacteriological 
tion, and the doctor remarks that the case invasion, and while in one case it may be 
could not have been one of sepsis because that the infection is mild, in another it may 
he had taken every precaution. My propo- be that of the severest type, 
sitiou is thai under the ordinary conditions It is not necessary to remove anything 
thai prevail al the present time, that given except what lies within the cavity of the 
a certain number of confinements there will uterus. When the infection extends to the 
be a certain number of infections, and when mucous membrane or beyond it is impossi- 
a fever develops after childbirth that the ble to remove with a curette all of the in- 
burden of proof rests upon the physician to fected tissue, and the use of a sharp curette 
prove that the case is not one of puerperal simply opens additional avenues for infec- 
sepsis. From such a point of view we can tion. After the exploration and removal is 
render great service in the treatment of this completed the uterus is dried with cotton on 
condition. There are so many grades of a pair of dressing forceps, and after drying- 
infection that it would be difficult in the it is freely swabbed out with a pledget sat- 
short space of time which I propose to con- urated with Churchill's Tincture of Iodine, 
suine, to thoroughly outline the methods of In the majority of cases it is not necessary 
making a differential diagnosis. The one to provide drainage, and under any circum- 



stances gauze drainage is objectionable. If 
the uterine cavity does not drain freely a 
rubber tube should be inserted. After the 
first curettement no other is necessary, but 
each day afterward the uterus should be 
swabbed out with iodine in the same man- 
ner until the temperature reaches normal 
and remains so for several days. When 
this treatment is used promptly and the 
temperature at once drops to normal no 
other application of iodine may, be neces- 
sary, but when there is a delay in treatment 
great caution should be observed in dis- 
continuing daily applications. 1 have ob- 
served cases in which the patient appeared 
to be entirely recovered, but in which the 
discontinuance of the treatment resulted in 
a return of the malady. The explanation 
was doubtless that the organisms had had 
their growth inhibited by the use of the 
iodine but that they had not been entirely 

T believe that in iodine we have the ideal 
antiseptic for this condition for the follow- 
ing reasons: It is, in the first place, a most 
efficacious antiseptic and destroys bacteria 
with which it comes in contact. In this it 
does not differ from many others. It has 
in addition, however, the property of pene- 
trating, so that in the soft, boggy uterus 
found in infection the action is not confined 
to the exposed surface but is continued into 
the muscular tissue of the uterus. In addi- 
tion to this the iodine is absorbed and as 
the absorption is continued along the same 
channels as the absorption of the toxines, 
the iodine not only sterilizes the endomet- 
rium and the walls of the uterus, but the 
lymphatic channels as well. 

I am led to offer these observations be- 
cause I have so frequently been called upon 
in cases of puerperal infection which ap- 
peared of the gravest character and which 
excited great apprehension on the part of 
the attending physician, in which this line 
of treatment has resulted in a prompt and 
complete recovery. In cases that are de- 
layed there may be a great many complica- 
tions and conditions arising, where this 
treatment, of course, cannot reach the seat 
of disease and is consequently not indicated; 
but to deal with all of these complications 
and their appropriate treatment would be 
foreign to the purpose of this paper. It is 
simply to set forth that puerperal sepsis 
does exist at the present day, that it may 
exist in spite of the most painstaking care 
of the attending physician, and that it can 
be almost invariably cured promptly if 
promptly recognized and properly treated. 

Treatment of Prostatic Hypertrophy ,with 

Report of Cases Operated on by the 

Perineal Method. t 

By J. Shelton Horsley, M.D., Richmond, Va., Pro- 
fessor of Principles of Surgery and Clinical Sur- 
yery in the Medical College of Virginia; Surgeon 
to Memorial Hospital. 

Every general practitioner sooner or later 
has the problem of how to treat prostatic 
hypertrophy thrust upon him. As I prac- 
ticed medicine in the country for several 
years, I personally know how perplexing a 
question it is to decide just what is to be 
done with an old man who suffers from re- 
tention of urine, due to an enlarged prostate, 
when it is impossible to pass the catheter 
that the country doctor usually carries. 
Something must be done to relieve the con- 
dition, and without a supply of catheters of 
assorted sizes, shapes, and material, such 
as the hospital surgeon enjoys, relief is often 
urgently demanded, when it seems for the 
time being impossible. In considering these 
cases we should first of all consider the 
patient and not the disease. If, for instance, 
he is otherwise healthy and with normal 
heart and arteries, and not the subject of 
organic kidney trouble, morphine can be 
safely used to bridge over the immediate 
situation until local applications may reduce 
the congestion of the urethra and prostate, 
or until other catheters or an aspirating in- 
strument can be obtained. However, in a 
patient who is old and feeble, whose heart, 
arteries and kidneys are all affected by 
sclerosis, and who already has symptoms 
of uremia, such as mild delirium, morphine 
will be contraindicated, and too much time 
cannot be wasted before evacuating the 
bladder. This is true not only because 
such patients stand both pain and morphine 
badly, but because if the bladder of a 
nephritic case becomes greatly distended, 
when it is emptied suppression of urine is 
much more likely to occur from the result- 
ing hyperemia that affects the kidneys than 
would be the case in a patient whose organs 
were practically normal. 

The first thing to do in any case of reten- 
tion of urine from an enlarged prostate is to 
examine the patient thoroughly. If you 
have previously treated him, and are ac- 
quainted with any diseased condition, so 
much the better; but even then the patient 
should again be gone over. His tempera- 
ture should be taken, his heart, lungs and 
general vascular system examined. After 
this examination, which on account of 
urgency must often be hasty, the prostate 
itself should be examined through the 
rectum . This step is exceedingly important, 

tRead before the Tri-State Medical Association 
meeting at Charlotte February 18, 1908. 



for it gives the practitioner a much more 
intelligent idea of the pathological condi- 
tion he must treat. Sometimes a large 
prostrate almost filling the whole rectum is 
found. Again a small and firm prostate 
that may act somewhat as a ball valve can 
be detected. Again it may be determined 
that the trouble is due to an old stricture 
and not to prostatic trouble at all. An en- 
larged prostate practically never accom- 
panies stricture, particularly if the stricture 
is of small size. This is due to the fact 
that the anatomical conditions about the 
prostate are such as to render the growth of 
this gland likely to protrude into the blad- 
der more markedly than at other points on 
account of this direction being the line of 
least resistance, and the hydrostatic pres- 
sure from urine dammed back by the stric- 
ture prevents enlargement of the prostate. 
Having determined which of these three 
conditions exists, that is whether there is a 
large or small prostate, or whether there is 
a stricture, the practitioner can select a long 
catheter if he has several; or, at least, he 
can be prepared to introduce a catheter to 
its extreme limit, as a very large prostate 
frequently lengthens the urethra from its 
normal eight inches to twelve. If, on the 
other hand, a small prostate is felt, the in- 
strument can be chosen or introduced ac- 
cordingly. If there is a stricture, filiform 
bougies may be used, which, of course, 
would be of no avail but positively danger- 
ous in prostatic hypertrophy. After hav- 
ing examined the patient, if there is much 
pain and the symptoms are very acute it 
may be necessary to give morphine hypo- 
dermically. It would be well to keep the 
patient at rest, to have the room well heated, 
and hot applications applied over the blad- 
der just above the pubis. This is better 
than the ordinary Sitz bath, where the posi- 
tion of the patient is such as to induce con- 
gestion of the prostate from gravity, and 
likely to chill him in other portions 
of his body. However, if the room is very 
warm and hot applications do not avail in 
bed, the Sitz bath may be resorted to. An 
enema of a pint of salt solution sometimes 
helps matter materially. In acute cases 
where the prostate is very tender and rather 
soft, these measures should be first tried for 
several hours before attempting to pass a 
catheter. Not only is the danger of infec- 
tion very great in such instances, but the 
tissues being soft may be easily penetrated, 
and considerable hemorrhage may result, 
together with a raw surface which is most 
likelv to be a point of infection. In pati- 
ents who have had numbers of attacks, 
and whose prostates are firmer, the catheter 
may lie passed more promptly. 

It is probably not necessary to urge the 

great importance of extreme care in asepsis 
in such cases. Physicians are too likely to 
remember chronic prostatics who pass the ca- 
theter themselves every day without infec- 
tion, and forget that the local condition of the 
tissues in such chronic cases is well prepared 
to resist infection, whereas in the acute cases 
of retention, such as we are considering, 
the slightest infection is likely to be taken 
up by the prostrate and dire consequences 
may result. The urethra should be care- 
fully washed out with some mild antiseptic, 
and the vaseline should be boiled. This 
can easily be done by putting a small 
amount of it in a bottle and placing the 
bottle in the same water in which the ca- 
theter is boiling, while the physician is 
cleaning his hands and washing out the 
urethra. Too frequently, after careful 
preparations in other respects, the whole 
result is vitiated by the use of some lubri- 
cant that is not sterile. 

All these things can be done in any log 
cabin, and there is no excuse for neglecting 
them. The catheter should be a soft rub- 
ber catheter, and should be well annointed 
with the sterile vaseline to prevent any 
injury by rough places scratching the 
urethra. If it is found to be impossible to 
introduce the catheter, a five per cent, solu- 
tion of cocaine, or a solution of adrenalin, 
about one part of the stock solution to two 
parts of water, may be injected into the 
catheter with an ordinary glass syringe. 
Not more than two drachms should be in- 
jected. After waiting five or ten minutes, 
sometimes the congestion is so relieved that 
the catheter can be readily introduced. 
However, should this not be possible other 
catheters may be used. Force should never 
be attempted. As a rule, if a small sized 
soft rubber catheter cannot be gotten into 
the bladder after careful attempts to pass it, 
prolonged efforts with stiffer catheters are 
of no avail. If the patient has had several 
attacks before and the tissues are hard and 
firm a stiff catheter can be used with much 
less danger. 

If the bladder cannot be entered by a 
catheter used in the manner recommended 
and if the applications have proved ineffec- 
tual, the bladder should be aspirated just 
above the pubis after making a short incis- 
ion in the skin. This, of course, should be 
done aseptic ally. It is not necessary to 
have a complicated apparatus, such as 
Potain's aspirator which frequently gets 
out of order. An ordinary aspirating needle 
is the only essential, and every doctor 
should carry this with him. The necessary 
suction can be made by slipping a small 
piece of rubber tubing over the large end 
of the aspirating needle, and connecting 
this with one end of an ordinary Davidson 



syringe; or a simple glass syringe such as 
used in injections for gonorrhoea may be 
used to draw off the urine, connecting it 
with the aspirating needle by a piece of 
rubber tubing. While practicing in the 
country I have used this procedure with 
considerable satisfaction. The apparatus 
is exceedingly simple and inexpensive. 
Aspiration may be repeated every day for 
two or three days if necessary. An internal 
urinary antiseptic, as salol or urotropin, 
should always be given. If after this time 
it is still impossible to get a catheter into 
the bladder, the patient should be operated 
upon. The character of operation depends 
upon his condition. As a rule it is safer to 
do a simple suprapubic cystotomy for drain- 
age, and follow this in a few days, when 
the patient's condition is better, by a radi- 
cal operation. Sometimes, however, a pros- 
tatectomy done through the perineum may 
be justified by the good general condition 
of the patient. 

The next point is how to treat such a 
patient if you have been successful in over- 
coming the acute condition by means of the 
catheter. This depends entirely upon the 
subsequent course. If in spite of your care 
the bladder has become infected, as will 
occasionally happen, or if such